2013_0510CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE /11`'
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE
0/C/ 56
/ /11£,.
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.
C
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
Double Check Valve
Manufacturer
Model Number
1st Check
Serial Number 66 6 % 7
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
11 Atmosphere Vacuum Breaker
Size
Located At C'e? �� r� u., / t -- %
The above is certified to be true.
Firm Name l)c � Certified Tester C ,- xyt X
Firm Address f��' � � � 7 Cent. Testy No. 9�'000 7c)--"- Date /6' °1.3
7"x
Gauge # L0G v c / / T GAS 0
Date last accuracy tested IV _S l
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
Closed Tight X,
Leaked 3 Y ❑
Opened at
vSid
Opened at
oSid
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 ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name l)c � Certified Tester C ,- xyt X
Firm Address f��' � � � 7 Cent. Testy No. 9�'000 7c)--"- Date /6' °1.3
7"x
Gauge # L0G v c / / T GAS 0
Date last accuracy tested IV _S l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy