2014_0730_RPZ (4) C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE:������'`"f1��/�Itl.ir� �r'',�,�' Cc dv�//I`,.r i �l5%
The bacl�low prevmtioa asscmbly detaile� below has beea tested aad maintained as required by TNRCC
regulauons and is cerdfied to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
�� Reduced Pressure Principle C Pressure Vacu�Breaker
^ Double Check Valve ❑ Amnosphere Vacuum Breal:er
Manufacturer ���, �r.S Siu - -.�-l�
Model Number OL'�'/�.2 G.'_T` Located At ?l/S`c� �/�0/�'��� �7 L�
Serial N�ber ��/ �/�_
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check v alve Assembly
lst Check 2nd Checl: Reiief Valve Air Inlet Check Valve
Initial Test DGClosed Closed Ti,Qht ed at Opened at nsid
Tight Leal:ed o sid _osid
RP- �� sid �
Leai;ed o �'� Did not Opea o L,eake� �
�P�
aad
Matr�ials
Used
Test After DGClosed Closed Tight o ppeaed at ppeaed at �sid
Repair Tight a �sid osid
RP sid
The above is catifiod to be true.
Firm Name,�I���� C���n� Cerdfied Tessca J e Y Yy Sr�raO�
Firm Address��/,?G7��acv�,;,cTar?,�� Cat Testc No.B1�i�'lo(��'i Date � /`l
(�auge # ��r`�u x/rG' �j`�C,%
Date last accuracy tested�.��1
White- Customer's Copy Yellow - City Copy Pink -Tester's Copy