2013_0104 (15)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: !� k;�cl��s IU7S S• �;* ��
The bac0ow 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
Manufacturer L ,k4 L,,
Model Number M9 !'n A Q 1
Serial Number A 8s -19
Size
Located At Ale -L�-
The above is certified to be true.
Firm Name k--r c,1 71 Pig. l e c
Firm Address <��s -S a a, ; IF # �V
Gauge # 0 r1 I 0,p(1 f5 U
Date last accuracy tested'
Certified Tester is M.e z, //) • 6-1v -
Cert. Tester No. SPOD ( a 5 7f,- Date 1 L 0),3
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 a
Closed Tight ❑
Leaked ❑
Opened at
• 3, y psid
Opened at
osid
osid
RP- ' •U psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-___---psid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name k--r c,1 71 Pig. l e c
Firm Address <��s -S a a, ; IF # �V
Gauge # 0 r1 I 0,p(1 f5 U
Date last accuracy tested'
Certified Tester is M.e z, //) • 6-1v -
Cert. Tester No. SPOD ( a 5 7f,- Date 1 L 0),3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy