2013_0129 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAMLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
'2
LOCATION OF SERVICE: S-w.-.o
The baclMow 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
e uced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Maad4ctr= w� Size
Model Number 7,� q
Serial Number /% q G'
ON
Located At U�-�- 1, 1ato —Jc,—S
The above is certified to be true.
Firm Name A,1LT Certified Tester PzvkjLQa nk)
Firm Address 1�-t-. use . '7C 76� 44 Cett. Tester Na. / 3, Due
Date last accuracy tested g �• /�
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
10,S17
DC- Closed
Tight o?• Z
RP- _,psid
Leaked ❑
sed Tight Y
Leaked ❑
Z 'g
Opened at
vsid
Opened at
osid
Did not Open o
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
osid
------ nsid
RP sid
The above is certified to be true.
Firm Name A,1LT Certified Tester PzvkjLQa nk)
Firm Address 1�-t-. use . '7C 76� 44 Cett. Tester Na. / 3, Due
Date last accuracy tested g �• /�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy