2013_0122 (10)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE t--�-
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
ir,0,
The bad -Dow prevention assembly detailed below has bees tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
�i Double Check Valve
Manufacturer�~��
Model Number
Serial Number �U
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
0 Atmosphere Vacuum Breaker
l�
Size l
Located At c.r
The above is certified to be true.
Gauge #,37x3 s3
Certified /
Cat Tester •I YZ.� D.
Date last accuracy tested / -o`?a - a 013
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 Ab
Opened at
Opened at
___ps id
pct�"
Tight l�'
RP- �? -L.
Leaked 0
Leaked o
L �
_psid
_�osid
Did not Open o
Leaked �
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ sid
Repair
Tight C3
nsid
csid
RP d
The above is certified to be true.
Gauge #,37x3 s3
Certified /
Cat Tester •I YZ.� D.
Date last accuracy tested / -o`?a - a 013
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy