2015_0611 (4) C�iECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # '
LOCATION OF SERVICE: f�1 � C� ,�- � 5 � , x�x D t'� <a:=�',�'E� �� �
The baci.-flow prevmtion assembly detailed below has beea tested aad maintained as requircd bv TNRCC - .
regulations aad is certified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle e Pressure Vacuimm Breaker
D Double Check VaIve o Atmosphere Vacuum Breaker
�
Manufact�er ! y �: ; '`% S� �/U
Modei Ivimmber �l �1�Y Located At V�.e c.., � ,:� � �---7 r3
Scrial N�ber �4, Z , i ;,� X �.T C ✓
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Checic Valve
Inival Test DC•Closed Closed Tight ,,� O�ened at Opened at _osid
Tight �1 Leal:ed �o �•�_psid _nsid
R.P- �Z Dsid �-�
�;� ❑ Did not Opea o Leal:ed o
�P�
and
Mataials
Used
Test Aiter DC-Closed Closed Tight o Opeaed at Opeaed at _�sid
Repair Tight o flsid _�osid
RP sid
The above is certified to be o�ue.
Firm Name � �;:, �-�-C.� ��-�c �. r. � �n . �r.t Certifiod Testa r���a-, ., � �<.,,.,c �. <:E,� , y��..�� �
Firm Address i j``%��< <% � ,�., � � � �� •,,?.� ����`Cert ?estc No. �''`` �'"� "� S`; D� b � � f S
Gauge # >� ; .� � `
llate last accuracy tested �- � � �5
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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