2013_0716 (25)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:I r GU�'Snc? ?S /�� '✓ YC 111
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
2'
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer /s /� IhS Size
Model Number 9 Located At Y r `S c r
Serial Number r 23 2e 7
The above is certified to be true.
I,
Firm Name 'Ira
Firm Address
�b y
Gauge # G
Date last accuracy tested
Certified Tester e Y rT
Cert. Tester No. iJ A ` Date 2111,11412
M
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 0
Opened at
Opened at
nsid
Tight C
Leaked D
nsid
nsid
RP -_psid
Leaked o
Did not Open C
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
nsid
Repair
Tight C
psid
nsid
RP sid
The above is certified to be true.
I,
Firm Name 'Ira
Firm Address
�b y
Gauge # G
Date last accuracy tested
Certified Tester e Y rT
Cert. Tester No. iJ A ` Date 2111,11412
M
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy