2014_0523 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer r ° i)" Size
Model Number (i Located At
Serial Number Id
The above is certified to be true. ,p
1 t5 , I
Firm Name Certified Testa /n 6A
Firm Address
�1, ? 011 - I Cert. Testa No. Date
,Y -7S-a
Gauge #
Date last accuracy tested — /C "�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight ❑
RP -_ psid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
DSid
Opened at
oSid
Did not Open C3
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight 13
Closed Tight ❑
Opened at
Sid
Opened at
oSid
_� Sid
RP sid
The above is certified to be true. ,p
1 t5 , I
Firm Name Certified Testa /n 6A
Firm Address
�1, ? 011 - I Cert. Testa No. Date
,Y -7S-a
Gauge #
Date last accuracy tested — /C "�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy