2015_0422 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�3.OW PREV�NTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PwS: CITY OF COPPELL
PWS I.D.#
� LOCATION OF SERVICE: �-j�1�7 �a.� �'��..�
The bacl�low przvmtion asscmbly detailed below has bxn tested aad maintained as required by TNRCC
reguladons and is czrdfied to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacu�Brealcer
� Double Check Valvc D Am�osphere Vacuum Breal:er
Manufact�er � �'��.' Siu �i `l, ,
Model Ivumber ��'' Located At �,-z,.. � �,�...-�?r
Serial N�ber �r`��r 3��{!
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assrmbly
lst Check 2ad Checl: 'ef Valve Air Inlet Check Valve
Inival Test DGClosed osed Ti,Qht Opeaed at Opeaed at nsid
Tight �, �� Leal:ed ❑ �sid _osid ,
�� �1 �'�l RP-_Fsid Z Z
I,eal;ed ❑ Did not Opea o L,eal;e� ❑
�P�
and
Materials
Used
Test Aft,er DGClosed Closed Tight o Opened at Opeaed at _�sid
Repair Tight ❑ osid __osid
RP sid
The above is certifiod to be we.
� � ,�
Firm Name �w�� Catifiod Testa ! t�,Y�!�
�
' � Cat Testc No. ��`" ` g��`�'���,
Firm Addr�ess ' , �x.�>�7 > �>6`',� � Date
�,,�� d�.-. 7;. :r��rC�
Gauge # l�. i 3,�565
llate last accuracy tested �-/�,�Z � /,
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy