2014_0212 (8)CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 71,00f21' er- S'l%rC� SDO Fre e-Po r f'
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regWations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
2' Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer L(/Ar7r -5
Model Number X02 47 / 12 T
Serial Number / 47 733
Size 2 `
Located At uje s-f side-
The above is certified to be true.
Firm Name
Firm Address 7 0 9 7
Gauge # n (o I :3 0 3 0
Date last accuracy tested 71,7.5-113
Certified Testa 70A n b • �ra rG r ti
Cat Testa No.9P &0 -Z19S'/ Date 2 h ZI /4
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 0
Opened at
Opened at
psid
Tight e
Leaked 0
asid
vsid
a// ;I// Al
RP- 2.O psid
Leaked C
/ ,
Did not Open o
Leaked
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight 0
Opened at
Opened at
psid
Repair
Tight C
psid
psid
RP sid
The above is certified to be true.
Firm Name
Firm Address 7 0 9 7
Gauge # n (o I :3 0 3 0
Date last accuracy tested 71,7.5-113
Certified Testa 70A n b • �ra rG r ti
Cat Testa No.9P &0 -Z19S'/ Date 2 h ZI /4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy