2015_0626 (2) ��
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�LOW PREVENTTON ASSEMBLY TEST AND MAINTENANCE REPORT
NAI�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: I��S S • �.\�- � �� �•
The bacl�low prevmtion assembly detailed below has beea tested aad ma�nta�n� � nq� bv TNRCC
regulations and is cerdfied to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle e Pressurc Vacu�Breaker
^ Double Check Valve o Amnosphere Vacuum Breaker
ji.
Manufactiaer (en��5 Siu /
Model Ivumber ��I��� Locat�d At l�o�\\ (,� 5�O�Q
Serial N�ber ��'�S'a�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACiJTJM BREAI�R
Double Check v alve Assembly
lst Check Znd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Tight �d Opened at Opened at csid
Tight �1- Leal:ed ❑ r O psid _osid
�P/��/ RP-�•O �sid �.�-
�;� 0 Did not Opea o L,eal:ed �
�P�
and
Mataials
Used
Test After DC-Closed Closed Tight o Opened at Opeaed at �sid
Repair TighL a _�sid __,osid
R.P sid
The above is cerafied to be true.
Firm Name ����' C o��rr+e�c��.1 Certifiod Testa �`JG�� '�`'�-
I�ov 5. (.e�„1�rA1 �X�p.�.,y �3�x�
Firm Address �-r.�c-���^'�,� T,� Cat Testc No. vo1 3�Iq, Date
c�8�e � �3 i� 3�3 t�
llate last accuracy tested � � 3 ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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