2013_1205 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE y
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `� /Y� yy� s:
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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve n Atmosphere Vacuum Breaker
Manufacturer kv ?IS Size e Ap
Model Number 7 04 Located At ko /T 13.,,
Serial Number 7
The above is certified to be true.
Firm Name
Firm Addr= 0$39 4/
Gauge # l�9o39y
Date last accuracy tested -3-
Certified Tester rr 7
Cert. 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
Opened at
Opened at
osid
Tight 3..P
Leaked ❑
vsid
osid
RP- __psid
Leaked ❑
" %
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Addr= 0$39 4/
Gauge # l�9o39y
Date last accuracy tested -3-
Certified Tester rr 7
Cert. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy