2013_1212CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACi{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 150 S <///,
The baci low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
V
Manufacturer Vi/ i ( k -"r) 5
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Model Number C/ 5 t) t' �- Located At
Serial Number 3 3 S-5 `16, X L U
The above is certified to be true.
Firm Name
Firm Address .2 51 3 R< < 0, r-
Gauge # 61_(,_
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight C
Opened at
Opened at
osid
Tight o
Leaked C
osid
osid
RP- _psid
Leaked o
Did not Open O
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address .2 51 3 R< < 0, r-
Gauge # 61_(,_
Date last accuracy tested
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy