2015_1102 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: � `� C� ;�,-���r'�� �
The bacl�flow preveation asscmbly detailed below has beea tested aad maintained as required by TNRCC
reguladons aad is cerdfied to be operating within acceptablc paramtters.
TYPE OF ASSEMBLY
C Rcduced Pressure Principle ❑ Pressur�Vacuimm Breaker
.�'"�r pouble Check Valve o Amiosphere Vacuum Breaker
�
Maaufactsaer L�" L' �' ' "'" � Siu �`�
Model Ivumber
% S cJ Locatcd At l` ����'( � ,+,% � r�
Sezial Nimmber 6`'���� � �� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check v alve Assembly
lst Chetk 2nd Checi: Relief Valve Air Inlet Check Valve
Initial Test DGClosed Clos�d Tight � Opened at Opeaed at osid "
Ti�t�. '� � Leal:ed o �sid nsid
RP-_psid t�. /
I,�;� p Did not Opea o Leal:ed �
�P�
and
Materials
Used
Test After DC-Closed Closed Tight o Opeaed at Opeaad at �sid
Repair _ Tighi ❑ �sid osid
i- RP sid
T'he above is cettifiod to be true.
Firm Name � �-� -�-'°`-�'�� Certifiod Testc f�� ' � r'�� � C. ,� :/v,z` � �.-
}.. l �
R r -
�s�,.��� �� `��`�''.�s�'�.�'�:�� l�ert. Testc No. ��,� ��� ��� � � � � .�
Firm Addr�ss
f
(�auge #� C.�J�r � � `"�' 7
llate last accuracy tested ��J / ' ;) �
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy