2014_0213 (28)CIIECK ONE:
IRRIGATION
DOMESTIC
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FIRELINE V
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #w�(
LOCATION OF SERVICE: Vk � �� X11 i1 ��• -} i1 C.c� h � T-A 7 j Ca ( q
The bac0ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C - Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At�'
The above is certified to be true.
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Firm Name n ek sA V `, r
Firm Address.,
Gauge #
Date last accuracy tested Vi i A 3
Certified Tester M\0_* ,
Cent. Tester No.`��'��ti��� Date
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
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked
sid
osid
RP- ._psid
Did Open ❑
Leaked ❑
Leaked
not
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
.____p sid
Repair
Tight ❑
vsid
nsid
RP sid
The above is certified to be true.
,..r.
Firm Name n ek sA V `, r
Firm Address.,
Gauge #
Date last accuracy tested Vi i A 3
Certified Tester M\0_* ,
Cent. Tester No.`��'��ti��� Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy