2014_1010 _ _, i
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINS �
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: ���Lr\,�� C.��
'Ibe bacl�low prevtation asscmbly detailed below has baa tested aad maintained as require� by TNRCC
re_guladons and is crrdfied to be operating withia acceptable parameters.
, TYPE OF ASSEMBLY
C Reduced Pressvre Priaciple ❑ Pressure Vacu�mm Brealcer '
� - ,''� Aouble Chxk Valve „ ; [�_ Amiosphere Vacuum Breaker '
�
Maaufact�er Siu 1.,
Modei Nimmbtr �d� Locatcd At 1�-�\2 C n�,�v��c�`
Serial N�ber �12��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULIM BREAKER
Doubie Check v alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Vaive
Ininal Test DGClosed Closed Ti,Qht � Opeaed at Opeaed at _csid
Tight �4. Leal:ed o nsid _osid
�,�� R.P-�psid
Leal;ed o � ��' D i d not Opea o L e a l;e d o
RePairc
aad
Mataials ;
� � Used � `- � -` ; -�
Test After DC-Closed Closcd Tight o Openod at Opmod at �sid
Repair Tight o _osid �,osid
RP sid
The above is cerdfied to be true.
Firm Name�@�, I�- ~r� Certifiod T
�1�5 w m��.s�-� �
F1Ia1 I�ddCCS$�►�x r.`nn r�,.`�_.T?C �S t(�� Cat Taster No. ` 2. D3iC _1�_1'-)
Gauge # ��f`�2.�i��
llate last accuracy tested �-Z1-��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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