2014_0602 (3)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:/ 3 3
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer L, ✓a� Size
Model Number 61- Located At
Serial Number
The above is certified to be true.
`d.Firm Name '
Firm Address X �G Pal n , fi .,
Say?
Gauge # �071(6/�
Date last accuracy tested
Certified Testes
Cert. Testa No. -`GG 7yG 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 ❑
Opened at
Opened at
nsid
�� SS
Tight ❑
RP -nsid
Leaked ❑
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
`d.Firm Name '
Firm Address X �G Pal n , fi .,
Say?
Gauge # �071(6/�
Date last accuracy tested
Certified Testes
Cert. Testa No. -`GG 7yG Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy