2013_0517 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
r
LOCATION OF SERVICE: U iL e
-, w � /O(A
The baclflow 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
❑
Double Check Valve
Manufacturer
0'� 4
Model Number
.__ ,
_ -.
7
Serial Number
t
i
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
'2,
Size
yof
Located At
The above is certified to be true.
Firm Name �'�� l � Certified Tester G �F
Firm Address t ( Cert. Tester No. '2' Date
Gauge # 771 1 l f
Date last accuracy tested
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 ❑
RP- -- --PSid
Leaked ❑
Leaked {� ❑
l�
psid
oSid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
--.psi d
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name �'�� l � Certified Tester G �F
Firm Address t ( Cert. Tester No. '2' Date
Gauge # 771 1 l f
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy