2013_0607CHECK ONE:
IRRIGATION DOMESTIC FIRELINE'
BAC QWW PREVENTION ASSEMBLY TEST AND MAMTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # -
LOCATION OF SERVICE: L ter
The bacldlow prevention assembly detailed below has been tested and maintained as regtured by TNRCC
reaulwons and is certified to be operating within acceptable Pte-
❑ Rcduccd Pressure Principle
❑/ Double Check valve
Manufactum .L,U I 1 n.s
Model Number 50
Serial Number 42 R 40 e7
TYPE OF ASSEMBLY
• Pressure Vacuimm Breaker
• Atmosphere Vacuum Breaker
rr
Size �-DC
Located At Frond O F I-a u ndrY
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Ched: Relief Valve. Air Inlet Check Valve
Initial Test DC- Closed
PdSS Tight 01
11 -� 513 Lid ❑
Repairs
and
Materials
Used
Test After DC- Closed
Repair Tight
RP
Closed Tight Er Opened at
Leaked ❑ _ csid
,2. �
Opened at I --oszd
d
Did not Open ❑ 1 Leaked
I Closed
❑ Ti ght Opened at
at I
--.PW -- ----per
_osid
The above is certified to be tr u.
Firm Name (-,S h tom' , V1 C �
Firm Address Lh
—)+C l50 tl -z , —T�L `75ZXD
Gauge # 0'10 Co l q 3
Date last accuracy tested
C 7 N3
Certified Tester
1-111 Cart � Tester No v Date _
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy