2011_1128 (3)CHECK ONE:
IRRIGATION DOMESTIC__ FIRELINE
BACTILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �Sf e e /�� d �–
The bacldlow 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 �- kS
Model Number U G)
Schal Number y 3
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
I/
Size
Located At
The above is certified to be true.
Firm Name I�C � 1 o ['c 1A t
Firm Address f � X30 ',( 2 '�- % ItA Y4'
Gauge # U U y l y
Date last accuracy tested �, �—/ /
Ce rufwd Tester
Celt Testa No. f c C'C D / -a J ' –% ate
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM
Double Check Valve Assembly
1st Check
2nd Check:
Relief Valve
Air Inlet
qBREAKER
CheInitial
Test
DC -Clos
Closed Tight
Opened at
Opened at
Tight /'
Leaked a - o
osid
oSid
RP -_pSid
Leaked C
Did not Open o
Leaked O
Reps
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
_ - sid
Repair
Tight O
osid
_.osid
RP rid
The above is certified to be true.
Firm Name I�C � 1 o ['c 1A t
Firm Address f � X30 ',( 2 '�- % ItA Y4'
Gauge # U U y l y
Date last accuracy tested �, �—/ /
Ce rufwd Tester
Celt Testa No. f c C'C D / -a J ' –% ate
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy