2012_0217 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: i 2.D ( E �Y'xy)d y Lea k c _
The bacltilow 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 C Pressure Vacuum Breaker
XDouble Check Valve C Atmosphere Vacuum Breaker
(,I% 4-16 size 6
Manufacturer I , .
Model Number -7 -(Q Located At � du � � O'V I tV, YI 6e—
Serial Number 1051711
The above is terrified to be true.
Firm Name " oo e %' Certified Testa V r7 ` ,,TChI
Firm Address Cat. Testa No. &W Date
Gauge # OL7 f f
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
?nd Check
C
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight ),
Leaked C3
Opened at
nsid
Opened at
nsid
nsid
RP -_,psi
Leaked o
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
�vsid
------ psid
RP sid
The above is terrified to be true.
Firm Name " oo e %' Certified Testa V r7 ` ,,TChI
Firm Address Cat. Testa No. &W Date
Gauge # OL7 f f
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy