2013_0716 (9)CHECK ONE: ,%
IRRIGATION DOMESTIC FIRELINE, V
BAOULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAh E OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: { i4
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer /Ni��,_ Size
Model Number s %� Located At i/ S L Y ( UD%7
Serial Number
The above is certified to be true.
Firm Name Md h "U % o ,in era Certified Tester
Firm Address �4,4'141 2 ruva vyMO Cat Tester No. p 8?iG Date
Gauge # O`r %O `-5" o
Date last accuracy tested /Q Q
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 s Ll ❑
Leaked ❑
vsid
nsid
RP -nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name Md h "U % o ,in era Certified Tester
Firm Address �4,4'141 2 ruva vyMO Cat Tester No. p 8?iG Date
Gauge # O`r %O `-5" o
Date last accuracy tested /Q Q
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy