2012_0810 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bacl&ow 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
+ate Double Check Valve ❑ Atmosphere Vacuum Breaker
Dil
Manufac=er e +°�� �. Size
Model Number D .L (' . Located At
Serial Number g ° "- 2-q
The above is certified to be true.
Firm Name A e-t,-�, s
Firm Address P v E 02 212 GJ
Gauge #
Date last accuracy tested %- 31 - t Z.--
Certifier) Tester
Cent Tester No.B dad 9 CIS rj Date Z'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ref Valve
Air inlet
Check Valve
1st Check 3,
2nd Check, Z . g
Initial Test
DC- Closed
Tight
Closed Tight W
Leaked ❑
Opened at
nsid
Opened at
_psid
_ nsid
RP- ._paid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
nsid
RP id
The above is certified to be true.
Firm Name A e-t,-�, s
Firm Address P v E 02 212 GJ
Gauge #
Date last accuracy tested %- 31 - t Z.--
Certifier) Tester
Cent Tester No.B dad 9 CIS rj Date Z'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy