2013_0717CHECK ONE:
IRRIGATION %k
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: S J %
The bad -flow 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
ffi Double Check Valve ❑ Atmosphere Vacuum Breaker
�s
Manufacturer
Model Number
Serial Number
,) C /r!
Size
Located At /'` e A' k
The above is certified to be true.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm
Address
1st Check
2nd Check
/ �'r'` "'`' r'�
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight / S,
Closed Tight 14
Leaked ❑
Opened at
nsid
Opened at
nsid
nSid
RP -_psid
Leaked ❑
Did not Open O
Leaked ❑
Reps
and
Ar 1 i114
Materials
Used
Test ABer
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ osid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm
Name lr.j ��
�` /lr �'
Certified Tester
Firm
Address
X ? '
� k� /' r`Cat. Tester No./,;
/ �'r'` "'`' r'�
"' Date
Gauge # 9 / 7,F el
Date last accuracy tested (/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy