2015-0130 (2) C�IECK ONE:
IRRIGATION DOMESTIC � FIRELINE
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �O IO�. �P Y1�U Y1~�f'►t� ,._}�c--��„ �l�a i �� � =� I I�
The bacl�low prcvention asscmbly detailed below has beea tested aad maintained as required by TNRCC
regulations aad is cetified to be operating within ac�eptable paramcters.
TYPE OF ASSEMBLY
�` Reduced Pressure Priaciple ❑ Pressurc Vacuimm Breaker
� Double Check Valve ❑ Amiosphere Vacuum Breaker
1��
Maaufactzaer 'V�� ft1- �"t"�"i `� Siu _
Modei N�ber `��`�1��� Located At �C'�t�t i Y1� fl� - ��5��"
Serial Nimmber ������i
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Checic Valve
Inival Test DGClosed Closed Tight Opeaed at Opeaed at _osid
Tight O Leal:ed o �i. -� psid osid
R.P-�,psid
�;� o Did not Opea o Leal:ed O
�P�
and
Materials
Usod
Test ARer DC-Closed Closed Tight o Opeaed at Opeaad at __nsid
Repair Tight ❑ nsid _osid
RP sid
The above is cati6ed to be ttve.
Firm Name�i��-��f�fm k�tn►r)�r�C , Certifi�Testa �"t"`t��c� � i `-���
Firm Address�'r"�,'`� -.2�=i�Co�i � Cert. Tester Na�`�'�Y'���t l�"`�DDDate
�-.C��u.��_�L' � � ��' i>C`.��i�;�::�`'�:'
(�auge # �'�,�i 1 i i I '�'j
Date last accuracy tested ( - -�() -- ��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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