2013_1202 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: The bacl.-flow 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
CS Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
7S'z 3
Gauge #
Date last accuracy tested ° -7-7011
Certified Tester
Cert. Tester No. Date Z 13
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 ❑
Leaked ❑
Opened at
Dsid
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
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
7S'z 3
Gauge #
Date last accuracy tested ° -7-7011
Certified Tester
Cert. Tester No. Date Z 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy