2012_0719CHECK ONE:
IRRIGATION DOMESTIC '� FIRELINE
BACuLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: SPIN y ! U
The baciflow 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 a Pressure Vacuum Breaker
tz' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer tt,�,k f x-'s
Model Number -S So
Serial Number
Size
Located At P-Ce", n
The above is certified to be true.
Firm Name A -Frr",L-
Firm Addrrss Po e, �/- 7c!!
Gauge # 0 7v9J0Y Ze
Date last accuracy tested F- 1-/1
Certified Tester
Cert. Tester No. F Fovd 416-' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 2, Z
2nd Check 2— 2,,
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Opened at
osid
Opened at
psid
nsid
RP -___- psid
Leaked ❑
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
_____osid
,__ psid
RP sir
The above is certified to be true.
Firm Name A -Frr",L-
Firm Addrrss Po e, �/- 7c!!
Gauge # 0 7v9J0Y Ze
Date last accuracy tested F- 1-/1
Certified Tester
Cert. Tester No. F Fovd 416-' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy