2014_0226CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE \ -,
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
V
r0l,
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
Double Check Valve
Manufacturer L......; ,"`' Vn
Model Number''`
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
1. rV IVI 1
The above is certified to be true.
8
Firm Name 1- �k. ; r,' `+ ' ' - +. c _ Certified Tester ' *", C,rl
Firm Address rays' 7r, Sit t °r`i =5' l Cat Tester No. 7 r �' ` Date ' 2c•
Gauge # CSC)-' ' 7 ]
Date last accuracy tested ;,-z •° 1
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
oZ' °��' w
Tight i
RP -_L
Leaked C
Leaked ❑
GW `
vsid
vsid
Did not Open ❑
Leaked O
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
vsid
RP sid
The above is certified to be true.
8
Firm Name 1- �k. ; r,' `+ ' ' - +. c _ Certified Tester ' *", C,rl
Firm Address rays' 7r, Sit t °r`i =5' l Cat Tester No. 7 r �' ` Date ' 2c•
Gauge # CSC)-' ' 7 ]
Date last accuracy tested ;,-z •° 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy