2014_0529 �.; .
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C�IECK ONE:
IRRIGATION � DOMESTIC FIRELINE j
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BACICF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT i
NAN�OF PWS: CITY OF COPPELL
PWS I.D. #
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LOCATION OF SERVICE: ���� <"�_�f���-�
The bacl�low preveation asscmbly detailed below has beea tested and IIl�ZLain� � nquired by TNRCC ,
regulations aad is cerdfied to be operating within acceptable paramttcs.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciplc � Pressure Vacuimm Breaker
�' Doublc Chcck VaIve o Atmosphere Vacuum Breaker
o , f /�
Manufacturer �'�"�i, ; Siu
Model Ni�ber G`��l� Locaud At �r-. f�"���'i
Serial Nimmber �11�7dU`��',_.�._— '
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alv�Assembly
lst Check 2nd Checl: Rtlief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti�f�'f �pened at Opened at osid
Tisht Leal:ed o �sid nsid
R.P- l�: �Dsid
�� p Did not Opca o L,ealced �
RePairs
and
Mataials
Used
Test Aft,es DC-Closed Closed Tight o Opeaed at Opmad at �sid
Repair Tight ❑ �sid osid
Rp sid
The above is ccrafied to be true.
Firm Name L� �'�-� ,��� i;,, ''� Certifiod Tata�� %"J.7�-�
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Firm Address ��y t-� //,,. � �,',�^,. f�Cert. Testc No.�. �'�'v�`�' Date �— �-_ f
f ���
Gauge # La >"/��i/l, �
llate last accuracy tested �y=;��r
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy