2013_0607CHECK ONE:
IRRIGATION DOMESTIC FIRELINE- / _
BALI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # —
LOCATION OF SERVICE: �R4cl
The back iow prevention assembly detailed below has been tested and maintained as mpured by TNRCC
regulations and is certified to be operating within acceptable parameters.
e Reduced Pressure Principle
Double Check Valve
Manufact = W o 1 K", n,5
Model Number 3 -90
Serial Number A,--7 q go'/ 6
TYPE OF ASSEMBLY
❑ Pressure Vacmnn Breaker
❑ Atmosphere Vacuum Breaker
r�
Size / DC
Located At La u n d r y
The above is certified to be true.
Firm Name
Firm Address
Gauge # O 9G & �� 3
Date last accuracy tested b—' ( 3
Certified Tester —�
�:u
Cerk Tests No ��' D�
White - Customer's Copy Yellow - City Copy Piz* - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAIM
Double Check Valve Ably
Relief Valve.
Air inlet
Check Valve
1st Check
2nd Check
DC- Closed
Tr& °2 o-
Leaked o
Closed Tight e
Leaked ❑
Opened at
_____psid
Opened at
� d
Did not Open 0
__—I)s id
Leaked o
Initial Test
Pass
I f-►3
Repairs
and
Materials
Used
Teat After
Repair
DC- Closed
Tight o
Closed Tight O
Opened at
°�
Opened at
- ---�od
RP
The above is certified to be true.
Firm Name
Firm Address
Gauge # O 9G & �� 3
Date last accuracy tested b—' ( 3
Certified Tester —�
�:u
Cerk Tests No ��' D�
White - Customer's Copy Yellow - City Copy Piz* - Tester's Copy