2014_0227CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: J &Mn &/.
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.
C7
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
Double Check Valve
Manufacturer
Model Number
Serial Number
2nd Check
TYPE OF ASSEMBLY
Cr Pressure Vacuum Breaker
C7 Atmosphere Vacuum Breaker
Size 8
The above is certified to be true.
Firm Name L-��tirp�l- naT►"�
Firm Address Y(U. xi`��Ftv,Tx
—76r7�
Gauge # Qo7317Y
Date last accuracy tested l2-,3 - /,3
Certified Tester
Cert. Tester No. A,000LN4L Date Z 27
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 ,ff
Opened at
Opened at
osid
Tight
RP- 2&e psid
Leaked o
Leaked o
�,
osid
osid
Did not Open o
Leaked O
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sia
The above is certified to be true.
Firm Name L-��tirp�l- naT►"�
Firm Address Y(U. xi`��Ftv,Tx
—76r7�
Gauge # Qo7317Y
Date last accuracy tested l2-,3 - /,3
Certified Tester
Cert. Tester No. A,000LN4L Date Z 27
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy