2014_0213 (14)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE v
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:.UQ Sa -) S O r _I
The bacldlow 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
❑/ Reduced Pressure Principle C Pressure Vacuum Breaker
( Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer '�cb C O Size
��
Model Number � 2 1 Located At `
Serial Number U q 013 5
The above is certified to, be true.
Firm Name Eck cry
Firm Address 7 g a q '5-T
IPWA5 Tx 75�l
Gauge # :�; 317 <S q
Certified Tester W-V\Q t�
Cert. Tester No.��'�� �� Date 3 1
Date last accuracy tested -k �121
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
Tight o
Leaked
psid
nSid
�1
RP- pSid
Leaked ar
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__ psid
Repair
Tight ❑
psid
nSid
RP Sid
The above is certified to, be true.
Firm Name Eck cry
Firm Address 7 g a q '5-T
IPWA5 Tx 75�l
Gauge # :�; 317 <S q
Certified Tester W-V\Q t�
Cert. Tester No.��'�� �� Date 3 1
Date last accuracy tested -k �121
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy