2014_0204 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE'
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ' 31 o��rGIX
The back(low prevention assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
V Double Check Valve
Manufacttzra W r k k- L' S
Model Number Ct S-D Z) h
Serial Number 0 9A J y
11�,
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
t1
Sint �c /
Located At �J �'t�n +'� (�►' L t ✓1 Q�
The above is certified to be true.
Firm Name. h Q - I ?NAVC,� ; IS, CatMed ?ester b J4 cv1
Firm Address G A,44501 L Cat Testa No. 00 / V 7 Date /
n li4 s r Tx 45- -936
Gauge # S-0 l Q
Date last accuracy tested 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
17
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened It
Opened at
-- id
�Ass
Tight
RP- Isid
Leaked ❑
Leaked ❑
p
l '
psid
_ psid
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
asid
Repair
Tight o
nsid
_- sid
RP sid
The above is certified to be true.
Firm Name. h Q - I ?NAVC,� ; IS, CatMed ?ester b J4 cv1
Firm Address G A,44501 L Cat Testa No. 00 / V 7 Date /
n li4 s r Tx 45- -936
Gauge # S-0 l Q
Date last accuracy tested 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy