2012_0716 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKa'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: N\X
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer Size
Model Number �bSG Located At
Serial Number�`131�
The above is certified to be true.
Firm Name RA 1414
Firm Address
Gauge # %40 -AN– ,%b
Date last accuracy tested -111(citl
Certified Tester
Cat Tester No. DQDO'ttu ___ Date �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 /
Tight
RP-2-0 ,psia
Leaked ❑
Closed Tight
Leaked ❑
'� 'y
Opened at
osid
Opened at
osid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
flsid
Opened at
�nsid
_____--p sid
RP sid
The above is certified to be true.
Firm Name RA 1414
Firm Address
Gauge # %40 -AN– ,%b
Date last accuracy tested -111(citl
Certified Tester
Cat Tester No. DQDO'ttu ___ Date �3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy