2013_0912 (7)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC ULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 5 x',�it
The bac0ow 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
Manufacturer / ' t K s k' y
Model Number �^ --41
Serial Number o00 6 y 36
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size t
Located At ` ✓. ux, 1 / "a / 5 /. , , -
The above is ccrtified to be true.
Firm Name l%�� ✓ ��je Certified Tester
Firm Addrs` X 7 `�
es u'a`�a Tx Cent Tests No.J6,c>G e Date
Gauge # 4f� 66 el f 7 �7 0
Date last accuracy tested '-/ - -5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
�/a 5
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC -Clos i
Tight
Closed Tie t N
Leaked ❑
Opened at
osid
Opened at
oSid
osid
lz -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
n sid
Repair
Tight ❑
nsid
oSid
RP sid
The above is ccrtified to be true.
Firm Name l%�� ✓ ��je Certified Tester
Firm Addrs` X 7 `�
es u'a`�a Tx Cent Tests No.J6,c>G e Date
Gauge # 4f� 66 el f 7 �7 0
Date last accuracy tested '-/ - -5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy