2012_1001 (7)CIIECK ONE:
IRRIGATION
DOMESTIC
. AARICk" l
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #t
CITY OF COPPELL
LOCATION OF SERVICE: C,-. Ile
The baciilow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer Z Je-4 4 s
Model Number 0() -7#ti t
Serial Number , qX `E6 j
TYPE OF ASSEMBLY
12 Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size `'
Located At orr w r -* (
The above is certified to be true.
Firm Name Dive(s4te -d Fi vv
Firm Address ' . =4 d� IL
Gauge # L 1121
Date last accuracy tested '7.12 • /2
Certified Tester Se nit
Cert. Tester No. `''� "' `'' ` r ° Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
psid
RP- i. Il psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name Dive(s4te -d Fi vv
Firm Address ' . =4 d� IL
Gauge # L 1121
Date last accuracy tested '7.12 • /2
Certified Tester Se nit
Cert. Tester No. `''� "' `'' ` r ° Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy