2014_0529 Y
C�iECK ONE:
IRRIGATION�_ DOMESTIC FIRELINB '
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
N�oF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � �� �� <-'i.-::, �� '
The bacictlow preveation assembly detailed below has been tested and maintained as require� by TNRCC
reguladons aad is cerdfied to be operating within acceptablc parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressur�Vacui�Breaker
� Double Chxk Valve 0 Amiosphere Vacuum Breaker
�' ' � /;
Maaufactsaer �/�li.; Siu
,-,,,/ � i, r
Model Iv�ber `'�-�`� I.ocaua At i�-, �� �i ��.-
Serial N�ber f"�����1�7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check v alv�Assembly
lst Check 2nd Checi: Reiief Valv� Air Inlet Check Vaive
Ininal Test DGClosed Closed Ti�,h� � Opened at Opened at osid
Tight eal:ed o nsid , osid
RP- r � psid
I,�;� o Did IIOt Open O Leal:ed �
RePairs
aad
Matnials
Used
Test Aftet DGClosed Closad Tight o Opeaed at Opmod at _�sid
Repair Tight o �sid osid
R.P sid �
The above is certified to be orue.
,�
Firm Name /� ;�;�-r, '"r" _��,,,� �— Catifi�Testa <'� ✓����=�- �
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Firm Address ��'7 �-�, %,/, _ �,=`>9�;,f -��i Cert. Tesur No.��v����}� Date � __ -�_��
c�auge # G',i/t%�Gl y
Date last accuracy tested �: ;��
'�"'T—
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy