2014_0730_RPZ (12) _ _ _
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C�IECK ONE:
IRItIGATION DOMESTIC FIftELINE �-/
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:-�T��r�n ��l�c�d�/tf��e�'c� ,-,r�/� � �SG/ S
The bacl-flow prevmtion asscmbly detailed below has beea tested aad M_a�tain� � nq�� �, 'I'NRCC
reguladons and is ceitifie�to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle ❑ Pressurc Vacu�Breaker
^ Double Chxk Valve o Atmosphere Vacuum Breal:er
Maaufactiaer ����1`.� Siu � �/
Modei Number �'O ,-�fdyl2rl� Located At ���3C'd' I'OG't't�,+� �l�
Serial N�ber �:� lJ �7 d
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAKER
Double Check v alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Vaive
Inidal Test DGClosed Closed Ti�t Opened at Opened at osid
Ti � Leal:ed ❑ �.� psid _osid
RP�sid �, L�/
Leal:ed ❑ Did not Opea o Leai:ed O
�P�
and
Mataials
Used
Test ARet DC•Closed Closed Tight a ppeaed at ppmod at _�sid
Repair Tight ❑ Dsid _�osid
RP sid
The above is cerafied to be true.
Firm Name ��,�"Yr� �d/�1�I' Certifiad T�t�JL'YYC.� ��10U,�'
Firm Address �QA/��?Grc�'vihe _7��j�' Cert Tester No���o�GG9 Date .3G�
(3auge # ���(��f��
llate last accuracy tested�j`�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy