2012_0208CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE y"�'
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: oc - L����r� �� v�c., - S-I nIQS F�iC�
The backgow 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 ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 1,gA -fTS Size
Model Number -7 7 LILY D C. D A Located At SE o r r &4- �o p ; >, ✓�,,,
Serial Number 100.'5'-7b- --
The above is certified to be true.
Firm Name A 11 X51 �7
Firm Address F-0 4- Ida r-.+ k 7'7a< 76; Y 41
Gauge # oer 110 0 eo `I
Date last accuracy tested
Certified Tester
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
a n
Double Check Valve Assembly
Cert Tester No.
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
RP- a sid
Closed Tight
Leaked C3
Opened at
psid
Opened at
osid
osid
Leaked p
Did not Open o
Leased ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
Dsid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name A 11 X51 �7
Firm Address F-0 4- Ida r-.+ k 7'7a< 76; Y 41
Gauge # oer 110 0 eo `I
Date last accuracy tested
Certified Tester
�,y i0 n
Lsa �
a n
Cert Tester No.
Date
a k ra
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy