2013_0429CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
C
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Size
Located At ut -6 U ��
The above is certified to be true.
a
Firm Name � G ��. Certified Testa V
Firm Address?, it 6 V 12 1T Cat. Testa No. ` U IZ %Z 0 Date
Gauge # 630 q(j �C 2--,
Date last accuracy tested L '����
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 ❑
Tight,
RP-
Leaked ❑
Closed Tight ❑
Leaked C3
Opened at
vsid
Opened at
vsid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
a
Firm Name � G ��. Certified Testa V
Firm Address?, it 6 V 12 1T Cat. Testa No. ` U IZ %Z 0 Date
Gauge # 630 q(j �C 2--,
Date last accuracy tested L '����
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy