2012_0629 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 8,20 We-',A -SrMV (Q °k La d
The bad -now 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
e Reduced Pressure Principle a Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer rp kc Size
Model Number HC5 .y �) Located At ,ire. -A k I
Serial Number (a:�56Q 'J
The above is certified to be true.
Firm Name. 1 I C re n nj Se ( u r i -A/ Certified Tester I a c) re-1 i
Firm Address (l CC-tn LAY) Cert. Taster No. APC' /'/6, 4 -3Date )q- I Z
Fcr) TX 7fk I1 Q
Gauge # [ �} 3�� a �►
Date last accuracy tested (D --, -; s 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
_ 1 Z
Relief Valve
Air Inlet
Check Valve
1st Check 1
2nd Check I .
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Opened at
vsid
Opened at
nsid
nsid
PASS
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed not a
Opened at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name. 1 I C re n nj Se ( u r i -A/ Certified Tester I a c) re-1 i
Firm Address (l CC-tn LAY) Cert. Taster No. APC' /'/6, 4 -3Date )q- I Z
Fcr) TX 7fk I1 Q
Gauge # [ �} 3�� a �►
Date last accuracy tested (D --, -; s 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy