2013_0122 (24)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE A
BACI]'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: &444e -:91 07oPON 11 — %00:7
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
i%
Manufacturer N � � Size
Model Number Q -=' c L Located At �-` 3 —1
Serial Number l� J
The above is certifiers to be true.
Firm Name
Firm Address >,S--(a a -r1c�c 7S`c} 'f U
Gauge #372 3 5- 3
Date last accuracy tested
Certified Tester �4 �,-
Cert. Tester No Date
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 0,,
Opened at
Opened at
psid
Ti
RP �sid
Leaked ❑
Leaked o
psid
osid
Did not Open O
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
—___----psid
Repair
Tight ❑
psid
____--psid
RP sid
The above is certifiers to be true.
Firm Name
Firm Address >,S--(a a -r1c�c 7S`c} 'f U
Gauge #372 3 5- 3
Date last accuracy tested
Certified Tester �4 �,-
Cert. Tester No Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy