2013_0607CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC OWW PREVENTION ASSEMBLY TEST AND MAINTENANCE, REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: S (L4
The bacidlow prevaation 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
Maaufacturm �J� ► j h_�
Model Number 3
Serial Number
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
size DC
Located At L,&t- rid r y
The above is LLS certified to be true.
Firm Name t C , Pft�CJYA-) Certified Tester
(C j."' � Cat Tester N � �1, 26
Firm Address ��-
Gauge # 0 V 0 60
Date last accuracy tested
Cp— 7—t 3
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
2nd Check
DC- Closed a ,
Ti-* a
�--pad
Leaked ❑
Closed Tight
Leaked ❑
�`
Opened at
psid
Opened at
__psid
Did not o
Leaked s�
Initial Test
I (-a 5--)3
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed. Tight ❑
Opened at
psid
Opened at
- -°sid
— ___psid
RP
The above is LLS certified to be true.
Firm Name t C , Pft�CJYA-) Certified Tester
(C j."' � Cat Tester N � �1, 26
Firm Address ��-
Gauge # 0 V 0 60
Date last accuracy tested
Cp— 7—t 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy