2014_0811_RPZ C�IECK ONE: , r��, ��
IRRIGATION DOMESTIC ✓ FIRELINE
BACI�3,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL -
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PWS I.D. #
LOCATION OF SERVICE: I c� �D S e �lt�'_e.I.�. C�V''-� ��'-C.,IJi/',
The bacl�low preveation asscmbly detailed below has bcea tested aad maintained as required bv TNRCC
regulations aad is cerdfied to be operating within acceptable parameters.
� TYPE OF ASSEMBLY
� Reduced Pressvrc Principle ❑ Pressure Vacu�Breaker
^ Double Check Valve o Amnosphere Vacuum Breaker
Manufactiaer 'W fl �"-�'""� Siu �`� �
Modei Number �.�C�C)�7�e�Q�ated At �.��5 i�e / � � �- CG✓1�t�✓
Serial N�ber � -� ��l f�'+ � C�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Checic Valve
Inival Test DC•Closed Closed Ti�t t�'' Opeaed at Opened at nsid
Ti�t � Leal:ed o �.psid _osid
RP- `7.�Dsid
Leal;ed a Did not Open � Leal:ed �
RePau�
aad
Materials
Used
Test After DGClosed Closod Tight o ppened at ppeaed at _�sid
Repair Tight o nsid osid
RP sid
The above is cenified to be tcue.
Firm Name � '�C, Certifiod Tcsta ��E�l�tn �i_S�-,r�
� C�� � � �(�L
� Firm Address 8 �t���� f�'I � 1 x � �C�� Cert. Testa No.���7C�'�Date �,i-/ i --F�(
(3suge # C���d�c�����
Date last accuracy tested �-�j -1�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy