2013_1218_RPZ (8)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ' (Qr e 66011
The back prevention as�cm�bTy detailed below has b tested maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
1� Reduced Pressure Principle
Double Check Valve
Manufacturer 9)alTS
Model Number D 0 q
Serial Number 42-13gD
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
t/� r
Size / � / L
Located At A �ea. -* �P ] - Kn 'Pr Sj' n 1k
The above is ccr#fied to be true.
Firm Name ' Certified Tester % Y /to"- A !L4^
C�
Firm Address l 'b�brt. Tester NoA f�bO/4i %8'(v Date 12 /e''3
Gauge # 07/7 F
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
nsid
PS5
Tight
RP -sid
Leaked ❑
Leaked ❑
D psid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
sid
Repair
Tight ❑
-� sid
nsid
RP sid
The above is ccr#fied to be true.
Firm Name ' Certified Tester % Y /to"- A !L4^
C�
Firm Address l 'b�brt. Tester NoA f�bO/4i %8'(v Date 12 /e''3
Gauge # 07/7 F
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy