2013_1011 (4)CHECK ONE:
IRRIGATION
111#yP4VCQ
FIRELINE i/
BAC XFLOW 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 maintained as required by TNRCC
regulations and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacwnn Breaker
t,2� Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Z � ✓,19 t� ___ size
Model Number F d C �" — Located At
Serial Number g2 2 3 -S
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 d, Z
2nd Check
Initial Test
DC- Closed
Tight y;'
Closed Tight
Leaked ❑
Opened at
sid
Opened at
--.osid
RP- ____,.psid
Leaked p
Did not Open o
Leaked ❑
ReP�
and
Materials
Used
Test Af3et
DC- Closed
Closed Tight o
Opened at
Opened at
�sid
Reps
Tight C3
psid
RP
The above is certified to be true.
Fnm Name A . -u` =Tr J' CertiSed Tester , /4- rt P-`L _
Firm Address 7 9`7 Cent Tester No. S' 7 Date /_ 3
Gauge # a-7 v 9 b 4 d'9
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy