2013_0426 (4)CHECK ONE:
IRRIGATION
DOMESTIC AO
FIRELINE
BACTOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # N o y c
LOCATION OF SERVICE: `j C<) `� r► a
The back-flow 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 Reduced Pressure PrinciDle C Pressure Vacuum Breaker
' Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Wr y.S 5 Size
Model Number 062 th Located At LO.- T rw" 0 ,�� rL� :% 1.. E - c
Serial Number AJ, L b C I7
The above is certified to be true. Y,r ij
Firm Name Al 'Tr 0 a V v fe-
Firm Address PC) ^ -7 C17
Gauge # `j Uc� ;� le,! }
Date last accuracy tested �l /.3
Certified Tester [-- �k g we fit" t' Vt h --,
Cert. Tester No. (t01-0T' Date `4 )A i
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
DC- Closed
Closed Tight �P'
Opened at
Opened at
nsid
Tight I. q d P
Leaked a
nsid
nsid
RP- ._psid
Leaked o
Did not Open o
Leaked O
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight
psid
vsid
RP sid
The above is certified to be true. Y,r ij
Firm Name Al 'Tr 0 a V v fe-
Firm Address PC) ^ -7 C17
Gauge # `j Uc� ;� le,! }
Date last accuracy tested �l /.3
Certified Tester [-- �k g we fit" t' Vt h --,
Cert. Tester No. (t01-0T' Date `4 )A i
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy