2015_0320 (4) C�IECK ONE:
IRRIGATION DOMESTIC FIR.ELINE X
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
N�ME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATI�N OF SERVICE: /2 _3 �'r.� ��-S�� jO.E'.
The bacl�low prevendon asscmbly detailod below has beea testod and maiataiaad as roqui�d by TNRCC
regilaaons and is cerdfied to be opera�ng within acceptabk paramcters.
TYPE OF ASSENiBLY
e Reduced Pressure Priaciple e Pressure Vacu�Breaker
� Double Check VaIvc C A�aosphae Vactium Hreaker
���
Manufact�cr ����1��.5 Siu
Model Iv�ber 7�7 Loeated AL �rp�elu/� /'y/Qt/�
Seriai N�ba Of��" D�D�
REDLICED PRESSURE PRINC'IPLE ASSEMBLY PRESSLTRE V:�CUUM BREAI�R
I�uble Check Valv�Assembly
�`�S ist(�ec{c 2nd Cbeci: Rdief�alve Air Inlet Check Valve
Inidal Test DC-Closed� � Closed Tight a ���osid �d osid --'�d
Ti�t .'� �
�_��d 3-�
� p Did n�Opea o Lea�;e� �
�P�
aad
Matecials
Used
r�c� Dc-ci�� cto�r;� o o�a� o�a�c �a
Repair righc a osid �sid
Rp 'd
The above is ceraficd to be true.
Firm Naaee QC�-,�r �t�2 Q�s CertiSed Testa �Q�on �-vs�Ton _
Firm Addres.t�D(�o�747 Cati.Tater Na =� Date � � 5
GUQ�haC�rc� Tx
Gauge # D(v//007.5
Date lsst accuracy tested 3