2013_0629CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ✓
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 33 3 C re-5T-S rDj---
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable par=eters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
x Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Aare S Size (0 to
Model Number 71 (po S Located At prn C?D -1 L3 I' CQ &n
Serial Number n , t g 18a
The above is certified to be true.
Gauge # job J :_� j-1 e
Date last accuracy tested /2-- ,7-/ a1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
RP- -�psid
Leaked ❑
Closed Tight
Leaked ❑
Opened at
osid
Opened at
vsid
Did not Open o
vsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP ===2sidd
The above is certified to be true.
Gauge # job J :_� j-1 e
Date last accuracy tested /2-- ,7-/ a1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy