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2014_0128 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: The back low prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. ❑ Reduced Pressure Principle Double Check Valve Manufacturer U', �•.�`� Model Number �J C-) Serial Number A3-��A\s -- TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker C Atmosphere Vacuum Breaker - / Size ! -I Located At W(- "pelt, T�' � v :-" tole• ke t' The above is certified to be true. Firm Name 41rc A p V -", vV Certified Tester U -,-V i Firm Address v.`e qS w\e i Cent. Tester No. t Date ` ` OP ° Gauge # 0(oC)�\ Date last accuracy tested © A3 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 Tigh i` Opened at Opened at oSid Tight Leaked ❑ nsid oSid RP- __psid Leaked ❑ Did not Open ❑ Leaked ❑ and nd L' Materials Z' Used Test After DC- Closed Closed Tight ❑ Opened at Opened at osid Repair Tight Cl nSid osid RP sid The above is certified to be true. Firm Name 41rc A p V -", vV Certified Tester U -,-V i Firm Address v.`e qS w\e i Cent. Tester No. t Date ` ` OP ° Gauge # 0(oC)�\ Date last accuracy tested © A3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy