2013_1023 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is ccrtified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle 12 Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name Certified Te 1—�,�
ster
Firm Addres s� i ' f (� Cert. Tester No. i t ' t )` Date ? <`
Gauge #
Date Last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Tight ❑
Leaked ❑
nsid
vsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
psid
vsid
RP sid
The above is certified to be true.
Firm Name Certified Te 1—�,�
ster
Firm Addres s� i ' f (� Cert. Tester No. i t ' t )` Date ? <`
Gauge #
Date Last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy