2014_1010 C�IECK ONE:
YRRIGATION DOMESTIC FIRELINE ��'
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: '�Z3 C_�ub a�f,�
The bacicflow preveation assembly detailod below has baa tested aad maintained as required by TNRCC
reguladons and is cerdfied to be operating withia acccptable paramet�ers.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciple C Pressurc Vacui�Breaker �
� � Double Check Valve , :, � ; Amnosphtre Vacuum Breaker �
;�
Maaufact�er � Siu 1
,•
�
Modei Number �.bc�c�R Located At ��� C c�c,v��c���
Serial N�ber �'�lc�C^1� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check Valve Assembly
lst Check 2nd Checl: ReIief Valve Air Inlet Checic Valve
Inival Test DGClosed Closed Ti,Pht � Opened at Opeaed at nsid
� Tight � Leal:ed ❑ �sid _,nsid
�'� R.P- �'�sid �, �t
Leal;ed o Did not Opea o Leal:ed o
RePair�
aad
Mataials
� t_ � U� _ . _.�
Test After DGClosed Closed Tight o Opeaed at Opeaed at _�sid
Repair Tight ❑ �sid __nsid
R.P sid
The above is cectifiod to be true.
Firm Name w,� , . � � f Catified T
�t.r.� � j`Y� . �x>�.
Firm Adde+ess 1��,.�n��n c 1.,�� `,�T�'��I ic�_ Cert. Testa No,' � /S 2 .3 Date t�-� 1
Gauge,# C�-f I�I C���
llate last accuracy tested �-Z�- �y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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