2013_0612CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: / I-/
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
n
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
s iljx-xj a WA
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
^^'Ot
Located At
The above is certified to be true.
Firm Name VOW -5N Certified Tester
Firm Addre
Cert Tester No. P ^ U
ss Date
Gauge #
Date last accuracy tested 0 ' -7_1 1
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
nsid
Tight ❑
RP- ._psid
Leaked ❑
Leaked ❑
nsid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Altar
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name VOW -5N Certified Tester
Firm Addre
Cert Tester No. P ^ U
ss Date
Gauge #
Date last accuracy tested 0 ' -7_1 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy