2013_1011 (4)CHECK ONE:
IRRIGATION
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bacidlow prevention assembly detailed below has been tested and mamudned as required by TNRCC
regulations and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
t . Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer wa Size
Model Number '7e) % de-d Located At �°�'"'�"'✓ (s
Serial Number %/ 6 " L
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.
tad Check Z.#
initial Test
DC- Closed
Closed Tight
Opened at
Opened at
� d
Tight
Leaked C
paid
_psid
RP- _____paid
Lea W- p
Did not Open a
Leaked o
��
and
Materials
Used
Test After
DC- Closed
Closed Tight o
at
Opened at
I
Repair
Tight t3
- id
_ osid
RP
The above is certified to be am.
Firm Name A CatiSed Tester
Firm Address Po 89y4- 79`7 Cat. Testa No. St'a 122 Date / /3
pi --,.o -)go-
Gauge # d°761) 8 4 P9
Date last accuracy tested 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy