2012_1012 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE !/
BAC KPLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ///Zl�
The bacitilow pravcmon assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vaawm Breaker
Manufacturer /-V/ / Size
Model Number Located At
Serial Number //z- s- 83
Gauge # 07y � y e� e ??
Date last accuracy tested 7 31- 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CHECK ONE;
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 3.9
2nd Check 3 • D
Initial Test
DC- Closed
Tight ,,d
Closed Tight
Leaked
❑
Opened at
csid
Opened at
�psid
d
RP- ____,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed Closed Tight
Tight ❑
RP amml&d
❑ Opened at
__—,.psid
Opened at __,____ Wd
_psid
The above is certified to be true.
Firm Name
Certified Tester
Firm Address
i�� R P)d -Z �•✓A -5G
Cent Testa No. 8 P oav 6/57 Date O-
Gauge # 07y � y e� e ??
Date last accuracy tested 7 31- 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CHECK ONE;