2014-0620 (2) C�IECK ONE:
IRRIGATION ✓ DOMESTIC FIRELINE
BACT�'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
rr�OF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L'r��c�.t L ti.,r ✓e:,r F•<•.� � 3 � -� �r�- �'�-• �4,�
The bacl�low preveatioa assembly detailed below has beea tested and m�ta�*+ed as required by TNRCC
re_sulations aad is cetified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressure Vacu�Breaker
er pouble Check Valve o Atmosphere Vacuum Breaker
Maaufactzaer �� �'�v $iu 1
Model Ivumber ��`� Located At � � �'�✓ S W e�•►��� ��_v��•���
Serial Ni�ber � � � � � �' �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Cbecl: Relief Valve Air Inlet Checic Valve
Inival Test DGClosedZ-� losed Tight Opened at Opened at osid
Ti,�t Leal:ed ❑ �sid _�osid
RP-_psid 'Z ,5
I,�;� ❑ Did not Opea O Leal►ed �
�P�
and �
Materials
Used
Test After DC-Closed Closed Tight o ppeaed at Opmed at �sid
Repair Tight ❑ osid osid
R.P sid
The above is certified to be true.
Firm Name ��c�.�r.n c.rc� ����� � �9.,.� Certifi�d Testa 1�� �1 c /-'�' �P 2h G•r J;✓
Fi:m Address t�v��1 3�� Cert Testv No. ��5 zJ��' Dace �'i� Z`r -�">
�t,.1�^C.C.1.. 1/� 1 P C ��- �� ! � � .
CiaUg@ # � � 1 I C�� `�
Date last accuracy tested �`�-�"� �(
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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