2012_0119CHECK ONE:
IRRIGATION
DOMESTIC
Beier V, L-4-0 1) D5,
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer !r, -SAS
Model Number
-
Scrial Number r -7 r)
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size T
Located At
The above is certified to be true.
Firm Name ✓ Certified Tester
Firm Address. JIrv1 5 ,; Cat Tester No. 'A ( ('16 0 Date
Gauge #
Date last accuracy tested y
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 ,p
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
psid
oSid
RP- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name ✓ Certified Tester
Firm Address. JIrv1 5 ,; Cat Tester No. 'A ( ('16 0 Date
Gauge #
Date last accuracy tested y
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy