2013_0415 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: iCn�. L1�e
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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size /A
Model Number kT- Located At e le,�f l o
Serial Number 2-2126- 0/
The above is certified to be true.
Firm Namel-411L A � �! C . Certified Tester �C� ✓ nifll'nc.��!'
Firm Address 0 &vk / /,Z /A wTT4Cmt. Tester No Ml Date
—/t( 0 4�—
Gauge #
--t
Date last accuracy tested Z,
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
ened at
Opened at
vsid
Tight e
RP -sidj
Leaked ❑
.
`'7 Dsid
vsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_vsid
Repair
Tight ❑
t?sid
vsid
RP psid
The above is certified to be true.
Firm Namel-411L A � �! C . Certified Tester �C� ✓ nifll'nc.��!'
Firm Address 0 &vk / /,Z /A wTT4Cmt. Tester No Ml Date
—/t( 0 4�—
Gauge #
--t
Date last accuracy tested Z,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy