2014_0426CHECK ONE:
IRRIGATION C/ DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e Reduced Pressure Principle
.`� Double Check Valve
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Manufacturer 6"36.0 Size
Model Number F5-r) Located At
Scrial Number (-- 5-4'rZ-
G�
The above is certified to be true.
Firm Name 4.V QA-r2e p- ,
Firm Address 3qo I 6" P7zL,, 12-q
Gauge # 312 fv '5-rl
Date last accuracy tested 12-- 5— l j
Certified Tester —a- 7 �, -
Cert. Tester No.MQC�031 5Z 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 C
RP- sid
Leaked C
j
oSid
oSid
Leaked C
Did not Open C
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight C
osid
oSid
RP Sid
The above is certified to be true.
Firm Name 4.V QA-r2e p- ,
Firm Address 3qo I 6" P7zL,, 12-q
Gauge # 312 fv '5-rl
Date last accuracy tested 12-- 5— l j
Certified Tester —a- 7 �, -
Cert. Tester No.MQC�031 5Z Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy