2014_0408CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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.
C
n
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
4 -Fri; l
p �L%
Serial Number 1J� y'5�
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size /
Located At
The above is certified to be true.
Firm Name '' f Certified Tester
Firm Address �r 1 ,, Vii, 7l Cert. Tester No. ��u� VT k 'fDate
f� � -7 GT
Gauge # 41jjUIJ,Ll4
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
osid
,
Tight ❑
RP- sid
Leaked ❑
Leaked ❑
osid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name '' f Certified Tester
Firm Address �r 1 ,, Vii, 7l Cert. Tester No. ��u� VT k 'fDate
f� � -7 GT
Gauge # 41jjUIJ,Ll4
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy