2012_1012 (6)CHECK ONE: /
IRRIGATION DOMESTIC FIR.ELINE
RACXFLOW PREVENTION ASSEMBLY TEST AND MAINTEN. NCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �l�y
The bacidtow preve=on assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
tle
Reduced Ptessurt Principle
Double Check Valve
Model Number
Serial Number Eqq-1-3
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size
Located At
Gauge # o.7 v 91' Y-d'd'
Date last accuracy tested % 31 - (-2--
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air inlet
Check Valve
Ist Check /
tad Check 1,
Initial Test
DC- Closed
Tight
Closed Tight
Leaked 0
Opened at
osid
Opened at
_ psid
.p -id
RP -_psid
Leaked o
Did not Open 0
Leaked 0
Repairs
and
Materials
Used
Test After
Reps
DC- Closed
Tight C
Closed Tight 0
Opened at
_,.paid
Opened at
nsid
_____.psid
RP
The above is cetified to be true.
Firm Name ��— Catified Tester
Firm Address fro B o ;- '797 =_° Cat Testa No. 6/s 7 Date /_ o
Gauge # o.7 v 91' Y-d'd'
Date last accuracy tested % 31 - (-2--
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy