2013_0311_RPZ (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACHTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: c� S
l\) hiL� -�
1�
The bacldlow prevention assembly detailed below has been tested and i zaintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Lt 1 c
PRESSURE VA
Model Number
Serial Number
1 � X17 q -3 j
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size.
Located At a LL ftc�A,
The above is certified to be true.
Firm Name U t S`f U C-, (_ 4
G�
Firm Address ?J 1 iidL -W't & l ,
tw�a —Tx `f 3
Gauge # i 1 � ` )
Certified Tester ftA: - 4y-"
CtJUM BREAKER
Check Valve
osid
Leaked ❑
I
I
_ nsid
Cent. Tester No. Qo- 2- Date -- /1—/;
Date last accuracy tested Q _ Z 4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VA
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight i,o ❑
RP -_LLpsid
Leaked ❑
Closed Tight ❑
Leaked ❑
t v
g
Opened at
3 osid
Opened at
osid
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name U t S`f U C-, (_ 4
G�
Firm Address ?J 1 iidL -W't & l ,
tw�a —Tx `f 3
Gauge # i 1 � ` )
Certified Tester ftA: - 4y-"
CtJUM BREAKER
Check Valve
osid
Leaked ❑
I
I
_ nsid
Cent. Tester No. Qo- 2- Date -- /1—/;
Date last accuracy tested Q _ Z 4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy