2015_0910 C�IECK ONE:
IRRIGATION ✓` DOMESTIC FIRELINE
BACT�LOW PREVENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 7�2- S � C�v�l � r
The bacl�low preveation asscmbly detailod below has beea tested and maintained as required by TNRCC
regulauons aad is certified to be operating withia acccptable paramtters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle C Pressure Vacu�Breaker
� Double Check Valve ❑ Amiosphere Vacuum Breaker
Manufact�er
�P�iG� Siu �r�
Model Ivumber �S� Locat�d At '���'�'� � �`^ ���
Serial Nimiber
�I-_D (�-7 31� GsyK•nrv���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSiJRE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Chec]: Relief Valve Air Inlet Check Valve
Initial Test DGClosed Closed Ti,,�ht ,� Opened at Opened at nsid
��`j�/� Tight� � Leal:ed ❑ �sid _osid
� RP-�,'� psid �,�
Leal;ed o Did not Opea o Leal;ed �
airs
and
Mataials
Used
Test ARet DC-Closed Closed Tight o ppened at Opeaed at _�sid
Repair Tight o osid _osid
RP sid
The above is cerdfied to be true.
Firm Name '"'"' �`'�'"� � Catified Tester
�Jc����
Firm Address � � Z?OIIS� Cert Testa No. 'd I Z�?0 p��—�v I�
��' � 2��,.—o��
(�suge # Q�4 q0(�,(�Z
Date last accuracy tested 'f�� `1 r
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy