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2013_0715CHECK ONE: IRRIGATION_ DOMESTIC FIRELINE BACEILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION' OF SERVICE: -716 N i 6 c i U, C- 0 ppe f i, y, 7500 The bacL low prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. c/ 9 Manufacturer Model Number Reduced Pressure Principle Double Check Valve is Serial Number A O�z '7 t 1 TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker Size Located At *iA A�� The above is certified to be true. Firm Name e%2 k- � 3&p, Certified Testa DCLVA Weps { 76036 . Firm Addressti" � 3 c� C (V 17 Cat. Testa Na� ©Q 1' � 5 � Date � ((old D zo0TK5Q Gauge #1916 o .50 9 j �, Date last accuracy tested -1 =/ 2_ 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 7 15 J c '-� Tight RP -_psid Leaked C3 269 nsid osid Leaked Cl Did not Open ❑ Leaked ❑ Reps and Materials a � A , ! f Used Test After DC- Closed Closed Tight ❑ Opened at Opened at _ nsid Repair Tight ❑ nsid osid RP sid The above is certified to be true. Firm Name e%2 k- � 3&p, Certified Testa DCLVA Weps { 76036 . Firm Addressti" � 3 c� C (V 17 Cat. Testa Na� ©Q 1' � 5 � Date � ((old D zo0TK5Q Gauge #1916 o .50 9 j �, Date last accuracy tested -1 =/ 2_ White - Customer's Copy Yellow - City Copy Pink - Tester's Copy