2015-0130 C�iECK ONE:
IRRIGATION DOMESTIC ✓ FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: a��J C� N • �r���Yl Tf�'L) �,c�. �c�i�"t' �� I i �j
The bacl�low preveatioa assembly detailed below has beea testod aad maintained as requind by TNRCC
reguladons aad is cerdfied to be operating withia acceptablc parameters-
TYPE OF ASSEMBLY
� Reduced Pressure Principle � Pressure Vacut�Breaker
� Double Chxk VaIve � Amoosphere Vacuum Breaker
t �r
Maaufacuaer ��A�'�� Siu �
Model Number �C�r-f /`���Cj�� Located At �.C��.Et i�"�rrt E�..r�i�'" C�C7 5��
Serial N�mmba �J�� ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Chetk Valve Assembly
ist C3eck ?nd Checi: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Tight Opened at Opened at osid
Tighi ❑ Leal:ed o �.�+ Dsid _�usid
RP- << sid
Leal;ed o Did not Opea o Leal:e� o
�Pairc
aad
Materials
Used
Test ARer DGCloscd Closed Tight o ppeaed at Opea�at _flsid
Repair Tight o �Dsid _osid
RP sid
The above is certifiod to be true.
Firm Name��i_��n��S�r k��-I�t���.lr�Catified Testa �,�'"r�'+�ca r� �j„� ��v�
Fi:m Address� Q}``,��-�l�LJ ( Cat ?esta No.l-��7l?�f Date -
�--�.s..�s t=>y� i��`', �x;�%_�.;?�C`l�`t
� Gauge # C3 z� I C��(=3�i�-i'
llate last accuracy tested j -=�� --E►=�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy