2013_0905 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACICMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ?e c h,. f{
The bacifflow 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
❑ Reduced Pressure Pnncivle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name I Yo cymm
Firm Address pr l3 1,9 r4o= ✓, ire
Gauge # ' o �226 U
Date last accuracy tested t) `
Certified Testate 5i' yl00'k
Cat. Testa No. !_3 /'UOD STG (e c1 Date ' /4
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
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
0- ,,_psid
Leaked ❑
Dsid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
esid
Repair
Tight ❑
osid
esid
RP sid
The above is certified to be true.
Firm Name I Yo cymm
Firm Address pr l3 1,9 r4o= ✓, ire
Gauge # ' o �226 U
Date last accuracy tested t) `
Certified Testate 5i' yl00'k
Cat. Testa No. !_3 /'UOD STG (e c1 Date ' /4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy