2012_0627 (2)CHECK ONE:
IRRIGATION DOMESTIC FIREUNE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1 "t S /o.+-"—k
If
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
Meulations and is certified to be operating within acceptable paramc=.
e Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number b O �" 1
Serial Number
TYPE OF ASSEMBLY
0 Pressure Vacuum Breaker
0 Atmosphere Vacuum Breaker
tj
Size
Located At �: , 5,'L `4 S
The above is certified to be true.
d' �`�'�
�_ J
Firm Name " '-- ( t r ^L Certified Testes 3 � "P'' �' ` �• •
Finn Address e d fo* i t'? UMP"but. Testa No. (OP W3 q pate
Gauge # 0.1 1 2--7- $ 6 `6
Date last accuracy tested �" Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Cl
Closed Tight 0
Opened at
Opened at
__paid
t'
ight
Leaked 0
_psnd
_`mod
'
T p_
Did Open 0
Leaked o
T caked p
not
Repairs and
2 V
0 t��t?sU�
✓ r
Materials
��,°
Used
Test Afta
DC- Closed
Closed Tight (3
Opened at
Opeenw at
_____j)sid
Repair
Tight o
p sid
--- nsid
RP
The above is certified to be true.
d' �`�'�
�_ J
Firm Name " '-- ( t r ^L Certified Testes 3 � "P'' �' ` �• •
Finn Address e d fo* i t'? UMP"but. Testa No. (OP W3 q pate
Gauge # 0.1 1 2--7- $ 6 `6
Date last accuracy tested �" Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy