2012_0627 (3)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backnow prevemon assembly detailed below has been tested and maintained as required by TNRCC
regulanoonss and is certified to be operating within acceptable parameters.
c Reduced Pressure Principle
Double Check Valve
Manufacturer A i -L 0--)"
Model Number -7019
Serial Number � I
TYPE OF ASSEMBLY
C Pressure Vacuma Breaker
C Atmosphere Vacuum Breaker
size
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check I tad Check Relief Valve
Initial Test DC- Closed Closed Tight ❑ Opened at
Tight (� C Leaked ❑ d
RP _ _,psid 2 i Ly
Leaked ❑
Repairs
and
Materia
Used
PRESSURE VACUUM BREAKER
Opened as �d I osid
The above is c orti5ed to be am.
Form Name /'K- -� � t �- � 1 l .-e Certified Testa
Firm Address D o g % ��,A Ins r,� Cet. Testa No. t `�q 3 q Date - Z-7 - 1 Z
Gauge # C� `3 ( Z 2 � b `6
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy