2014_0213CHECK ONE: `
IRRIGATION DOMESTIC FIRELINE y/
BACEF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # Chn��,c� mE`�
LOCATION OF SERVICE: 40Q 9a) �� Tx -7501q
The bacldlow prevention assembly detailed below has been tested and maintained as required by MCC
regulations and is certified to be operating within acceptable parameters.
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
,,�-bco
<3a S Y
Serial Number �— 3 q q `
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size I /.)—.
Located At t`� 4 a% li� sF�,>
The above is certified to be true.
Firm Name -Tok K\
Firm Addr+ess� a �`
Gauge # 330<69
Date last accuracy tested �v
?5.-U7
Certified Tester M\ 0 --\ t
Cert. Tester No Date 13 1
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
Closed Tight ❑
=od at
Opened at
psid
\RP
Tight ❑
-_psid
Leaked
psid
_psid
'
Leaked
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Altar
DC- Closed
Closed Tight ❑
Opened at
Opened at
----.p sid
Repair
Tight ❑
_ -,psid
psid
RP sid
The above is certified to be true.
Firm Name -Tok K\
Firm Addr+ess� a �`
Gauge # 330<69
Date last accuracy tested �v
?5.-U7
Certified Tester M\ 0 --\ t
Cert. Tester No Date 13 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy