2013_1011 (2)CHECK ONE:
IRRIGATION L/
111,037 5
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /O
The bac 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
Cam, Reduced Pressure Principle a Pressure Vacuum Breaker
! Z' Check Valve ❑ Atmosphere Vacuum Breaker
Model Number Z 04.10
Serial Number'- A`4)Q—
Size
,2- .If
Located At 4-As� r/d-1--
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 Check 1,(a
2nd Check -L-0
Initial Test
DC- Closed
Closed Tight
ve
Opened at
Opened at
— id
Tight Ve
Leaked
o
_.psid
_osid
RP -_psid
Lea W. o
Did not Open O
Lea ked ❑
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight
o Opened at
Opened at .�sid
Repair Tight G
__psld
Dsid
RP
The above is testified to be true.
Firnn Name A
Certi w Tester r'o
a, L
Firm Address Po 8 ,-Y4. 79' i
Cert. Tester No. 19000 6 19-7 10-11-13
Gauge # 0-769,04-P9
Date last accuracy tested rd / /✓ 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy