2013_0607CHECK ONE:
HtHIGATION DOMESTIC FIRELINE-
BACIFLOW PREVENTION ASSEMBLY TEST AND MAINTTNANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # ryry —
LOCATION OF SERVICE:
The backnow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
0 1 Reduced Pressure Principle
0,1-' Double Check Valve
Manufaa= 1A)
Model Number 3 5 0
Serial Number )q 9 44 g
TYPE OF ASSEMBLY
C! Pressure Vacurmm Breaker
❑ Amwspbere Vacm= Breaker
Size / N�
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check V live Assembly
Ist Check 2nd Check' Relief Valve. Air Inlet Check Valve
Initial Test DC- Closed Closed Tight ar Opened at Opened at _—.?)sid
Tight ,2, - Leaked ❑ _ psid _ osid
-a 3 �d ❑ ` T Did not Open o Leaked o
Leaked
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight ❑ Opened atas. at �""�sia
liepair Tight ❑
RP 'd
The above is certified to be true.
Firm Name C`3� 114r�' ,
k Card ied Tester
1"� Addkrss
t Gl Cat Tester Noij � ") Date
- 11 -U-1, 7� `15
Gauge # `%D Co %Ot
Date last accuracy tested b_ -7—t-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy