2013_0905 (19)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAC MOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: e_�C c 14A c
The baclflow 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 Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer f� _ Size r
Model Number G Located At ";r �'. r �' nrh 114 /.% G
Serial Number
The above is certified to be true.
Firm Name 1 11h t 66 l�r�/I1�`j1
Firm Address 7 ' ? � Y .� /� , /� �► /
// /;, 'l _
Gauge # C �, � Z, S L'
Date Last accuracy tested I` /
J� Sc f
Certified Tester Y� �
Cat Tester No. ���''�� Date /
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
nsid
Tight
RP -�sid
Leaked ❑
osid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Firm Name 1 11h t 66 l�r�/I1�`j1
Firm Address 7 ' ? � Y .� /� , /� �► /
// /;, 'l _
Gauge # C �, � Z, S L'
Date Last accuracy tested I` /
J� Sc f
Certified Tester Y� �
Cat Tester No. ���''�� Date /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy