2013_0122 (32)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE A
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bad -Low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
-a
Double Check Valve
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Manufacturer
Model Number'
Serial Number
2nd Check:
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size QQ
Located At
The above is certified to be true.
Firm Name X22 =�' /. Certified Tester
Firm Address C-rj rl"64 Tic -7 5-43 410 Cert. Tester No. 6 10-17 3 Dente r k Q 5-° l 3
Gauge # 3 7 2 3 53
Date last accuracy tested /, -�l a - /3
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 X�
Opened at
Opened at
psid
Tight 0
Leaked ❑
Leaked ❑
osid
nsid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__psid
Repair
Tight ❑
nsid
psid
RP sid
The above is certified to be true.
Firm Name X22 =�' /. Certified Tester
Firm Address C-rj rl"64 Tic -7 5-43 410 Cert. Tester No. 6 10-17 3 Dente r k Q 5-° l 3
Gauge # 3 7 2 3 53
Date last accuracy tested /, -�l a - /3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy