2013_0308 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ge-
The bacldlow 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 ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
,r
Manufacturer 1� 2' f C'
Model Number
C/
Serial Number / �J G 1�
Size
Located At
The above is certified to be true.
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm Address
�� /��' �` 7`' '� l�`y
rr Cert. Tester No.
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Ti- t f
Leaked /13
Opened at
sid
Opened at
osid
_,osid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
__-_-p sid
Repair
Tight C
sid
_psid
RP sid
The above is certified to be true.
Gauge # &L,G)9 /7!�c
Date last accuracy tested �-/ /,2 -/3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
Certified Tester
Firm Address
�� /��' �` 7`' '� l�`y
rr Cert. Tester No.
>1� >�'`��a Date
Gauge # &L,G)9 /7!�c
Date last accuracy tested �-/ /,2 -/3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy