2015_0608 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTEN.a►NCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: 1 � C� 'jr .�,n.,� 1 � ���
The bacl�low preveation asscmbly detaile� below has beea tested aad maiataiaed as reQuired b�' TNRCC
regulanons aad is ceerrified to be operating withia acctptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressurc Priaciple ❑ Pressure Vacu�Breaker
� Double Check Valve o Amiosphere Vacuum Breaker
Maaufact�er �� L� �'i A �P�11Siu 3 �,
Model Iv�ber � P Z � �-1� Located At �i c=r��e. r+� e ��
Serial Ni�ber � r�� �I O
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
� Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DGClosed Closed Ti,,P.ht � ed at Opeaed at nsid
Ti�L- ❑ Leal:ed ❑ O��j 1._psid nsid
�fi�j R.P- �c sid ��'�
�� p Did not Opea o Leai:ed �
�P�
and
Materials
. Usod
Test After DC-Closed Closed Tight o Opened at Opened at __flsid
Repair Tight o �sid _nsid
Rp sid
The above is certified to be�ve. �'�� '
�j' D I n c�5�'�i C� Catified Testa �1 v�'� I►J „�''�1
Firm Name -
_ �
Firm Address� r �S�s`��(� d�C� �o�•a� ��� Cert. Testc No. ���'C)O�S�� Date � _
c�auge # � 2_ C.� "1 I LI 6 � .
llate last accuracy tested �{ - Z � !-]
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy