2013_1218_RPZ (4)CIIECK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # II
LOCATION OF SERVICE: a r •P S �° T 5(a
7O0
The bacld]ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Manufacturer
Reduced Pressure Principle
Double Check Valve
Wa4 5
Model Number d O Q%
serial Number o17aa"1k,5
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Y
size 2
Located At �I'tALiL' , r s1� `� lea o M
&e t , vvc Sy ru10 )&4k-
The above is certified to be true.
y i.e- r
Firm Name ��� j`e5� Certified Tester
Firm Address o i" 7(0 Zy�ert. Tester No. 8 ft/ Date
Gauge # 6(p0 %1%9
Date last accuracy tested
7- /o -�,3
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
Ist Cheri:
2nd Check:
Initial Test
P�(SS
DC- Closed
Tight
RP- psid
Leaked ❑
Closed Tight *
Leaked ❑
5.8
Opened at
;V .c2 Sid
Opened at
nSid
Did not Open ❑
Dsid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nSid
_ nsid
RP sid
The above is certified to be true.
y i.e- r
Firm Name ��� j`e5� Certified Tester
Firm Address o i" 7(0 Zy�ert. Tester No. 8 ft/ Date
Gauge # 6(p0 %1%9
Date last accuracy tested
7- /o -�,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy