2012_1012 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITE' OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
I
The ba .00w preva= assembly detailed below has been tested and maintained as requinrW by TNRCC
reguim= and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
c / Reduced Pressure Principle a Press= Vag Brealoer
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer scv Size - �
Model Number �a Located At A. � �---
Serial Number 1'9v
The above is catified to be true.
Firm Name r'�- Cemfied Tester Ah n.et'k
Firm Address Ir e gZ V- -797 !A// Cert. Testa No FP0- -0 X 15'7 Date
Gauge # o7,oao, 4,?
t
Date last accuracy tested / v - ht, - /-j�--
White - Customees Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY P
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve A
Air Inlet C
Check Valve
1st Check 2
2nd Check /. & R
Initial Test D
DC- Closed C
Closed Tight O
Opened at O
Opened at _
_*d
RP- ---.psid
Leaked o D
Did not Open o I
I =kad o
Repairs
and
Materials
Used
Test Mier D
DC- Closed C
Closed Tight o O
Opened at O
Opened at —
—gSid
The above is catified to be true.
Firm Name r'�- Cemfied Tester Ah n.et'k
Firm Address Ir e gZ V- -797 !A// Cert. Testa No FP0- -0 X 15'7 Date
Gauge # o7,oao, 4,?
t
Date last accuracy tested / v - ht, - /-j�--
White - Customees Copy Yellow - City Copy Pink - Tester's Copy