2014_0408r'
NQ
CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bac0ow 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 ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Nimmber ;�% � 1y
Size
Located At
The above is certified to be true.
Firm Name iii~, <<, Certified Tester
Firm Address Cert. Tester No. •< Date
.*iy l
Gauge # ? � all L
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
nSid
Tight ❑
Leaked ❑
nSid
nSid
RP- e. �Sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name iii~, <<, Certified Tester
Firm Address Cert. Tester No. •< Date
.*iy l
Gauge # ? � all L
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy