2012_0627 (4)CHECK ONE:
IRRIGATION ✓ DOMESTIC FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND N ADMENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
5,
The backilow prevention assembly detailed below has beea tested and maintained as required by TNRCC
regulations and is certified to be opai6ng within acceptable parameters.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number 0()-? __ 4 1
Serial Number (Q S14
TYPE OF ASSEMBLY
C! Pressure Vacuum Breaker
o Amrosphere Vag Breaker
2
size
Located At So LK 5,1 a, 51k . yw-�O<- 'ew +vq
7—o CG.wLt)- L of-
The above is cardfiedto be truer
Firm Name /VC4 1'0' 4 t' ,-t
Certified Testa � ux� (I -, 1116L h-,
Firm Address „ do,_ -7 q! (Ij A+z� t Tester No. Date / L
Gauge # d � I ti'I- � i b
Date last accuracy tested 5- ` 2- I -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Cluck Valve Assembly
1st Check
2nd Clink
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
.j d
Tight -L, U
Leaked ❑
sid
� d
�6-YT
RP -_ -psid
Leaked o
�- U
Did not Open ❑
Leaked C3
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
______gsid
Repair
Tight ❑
,� d
.�nsid
RP
The above is cardfiedto be truer
Firm Name /VC4 1'0' 4 t' ,-t
Certified Testa � ux� (I -, 1116L h-,
Firm Address „ do,_ -7 q! (Ij A+z� t Tester No. Date / L
Gauge # d � I ti'I- � i b
Date last accuracy tested 5- ` 2- I -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy