2013_0411 (23)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACEILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
Tx
The bacltilow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number l
Serial Number T5 ?'
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
Firm Address 1 n 4 C
Gauge # -- }
Date last accuracy tested ! (, I
Certified Tester
Ccrt. Testa No. `'` y 7 Date y 11
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
o
Tight ❑
Leaked C
nsid
osid
R.P -_psid
Leaked C
Did not Open C
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address 1 n 4 C
Gauge # -- }
Date last accuracy tested ! (, I
Certified Tester
Ccrt. Testa No. `'` y 7 Date y 11
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy