2015-0130 (3) C�iBCK ONE:
IRRIGATION DOMESTIC �ff FIRELINB
BACT�"LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: .� �C� N . �e.►�-��"O � � A C� 1��! - �U i�t��� I � ��
The bacl�low prevmtion assembly detailed below has beea tested and maintain� � nq�� bv TNRCC
reeulations and is cerdfied to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle ❑ Pressur�Vacu�Breaker
❑ Double Check Valve o Amiosphere Vacuum Breakec
Maaufact�aer
�.1�--E� -��, s� ,v-�r ,
Model Number �a� CC�T ��a At � Q u��n rr�er�� � 1 c.��-�-�
s��rr�t� �,�7 � �C.,o
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Cbeck Valve
Initial Test DGClosed Closed Tight Opeaed at Opeaed at esid
Ti�t o Leal:ed ❑ �.r�- Dsid _nsid
RP-�,psid
I,�;� p D i d not O pea o L e a l:e d O
�P�
aad
Mataials
Used
Test ARer DC-Closed Closed Tight o Opened at Opm�at ,__,�sid
Repair TighL o �flsid _osid
RP sid
T'he above is certifiod to be true.
t
Firm Name�i�c'm�A � �-�"(�v i)��,�Cetified Testa �,-�'� v e����l�" '
Firm Address �� 1__ Cat Tes�r Nd�-'. Date��
��i_ci��-',��C i�jC�.�? �
Gauge #��� � ' � ����
llate last accuracy tested _� �- �,�( �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy