2014_0212 (7)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE_�
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 500 Fi--e -eAor * ?/ -(141 -
The baciflow 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
or Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer l td /I7T.5 Size 0 10
Model Number 7 7 !Z b e- Dll Located At n/ Qar F,OG oh /�_ • Sic%
Serial Number / 06-115"00f
The above is certified to be true.
Firm Name , .;2ai 64•,,�rrr 5 line
Firm Address -7 f /01 'ik S'T
Arlih9-fvn .7')e
Gauge # Old 330 3 0
Date last accuracy tested 7/.2-5-/-/ 3
Certified Tester Ta A r 6-
Cert. Tester No/AP 00/ 5 3S'/ Date a 11.2 /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight e'
RP -j, -psid
Leaked p
Closed Tight te-
Leaked o
31 2
Opened at
osid
Opened at
osid
Did not Open o
osid
Leak ed o
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight 0
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name , .;2ai 64•,,�rrr 5 line
Firm Address -7 f /01 'ik S'T
Arlih9-fvn .7')e
Gauge # Old 330 3 0
Date last accuracy tested 7/.2-5-/-/ 3
Certified Tester Ta A r 6-
Cert. Tester No/AP 00/ 5 3S'/ Date a 11.2 /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy