2015_0508 (5) C�IECK ONE:
IR.RIGATION DOMESTIC � FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � k �-�� LU' r �U.'�, �' I �� �C�' I�
The bacictlow przvtation assembly detailed below has beea tested aad maintained as required by TNRCC
reeulauons aad is certified to be operating within acceptable parameters.
,�;rr TYPE OF ASSEMBLY
�� Reduced Pressvrc Principle C Pressure Vacui�Breaker
� Double Check Valve ❑ Amnosphere Vacuum Breal:er
Maaufact�ruer ,� � ��� Y1 � Siu
� r+
Model Number -1 � U Located At � i�T l�t � 1�� ���C�t�-�-;
Serial N�ber � ��'' �"
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check Valve Assembly
lst Check �nd Checl: Relief Valve Air Inlet C'becic Valve
Initial Test DGClosed Closed Ti,Qht Opened at Opeaed at nsid
Ti�t �' Leal:ed o nsid _osid
�- ��` � RP. � 1� Dsid S
�;� ❑ � � Did not Opea o I,eaked O
�P�
aad
Materials
Usod
Test Aftet DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair Tighi o osid _,osid
RP sid
The above is certi6ed to be true.
Firm Name �!�'Ci�� Y�1�.���1;��C� Certified Testa W �� �� `c�►''}'! �v� �j `�-y�
Firm,,�Address �f-'�� �� ��f�� � � Cert. Te.ster No. D I � Date �`�O� � � �
i��r�t nc� ir.`�i i��� `j"�� "'�JE'���
Gauge # a��� (�� �,�
Date last accuracy tested
�T � � �
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy