2013_0311CHECK ONE:
IRRIGATION DOMESTIC_� FIRELINE
BACXTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
Z) 6 L u Y-E-- �j At L S
LOCATION OF SERVICE: �, D Rol
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e Reduced Pressure Principle
Double Check Valve
Manufacturer \&j a±fs
Model Number
Scrial Number 4- 1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
t -
Size I �1,. to ? 6 e,,_
Located At `®fP �C� �1 g,,,
The above is certified to be true.
Firm Name 4AA C)
a V1
Firm Address I Zr) 0
6el%tlo, S` S
Gauge #) jb
Certified Tester ya U
Cert. Testa No. '' 1 Z Date
Date last accuracy tested _ �j� /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
Closed Tight 5�
Opened at
Opened at
nsid
Tight ❑
RP -,psid
Lcaked Cl
Leaked ❑
nsid
nsid
Did not Open O
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name 4AA C)
a V1
Firm Address I Zr) 0
6el%tlo, S` S
Gauge #) jb
Certified Tester ya U
Cert. Testa No. '' 1 Z Date
Date last accuracy tested _ �j� /L__
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy