2014-0620 (3) C�IECK ONE:
IR.RIGATION DOMESTIC � FIRELINE
BAC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAI�OF PWS: CITY OF COPPELL
PWS I.D. #
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LOCATION OF SERVICE: �' '��.r t L n�-�►-G C r�C y �� � S 1_�C�� �.. T4���
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The bacl-tlow preveatioa asscmbly detailed below has beea tested aad maintained as required by TNRCC
re_suladons aad is cerdfied to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressur�Vacu�mm Breaktr
� Double Chcck Valvc o Atmosphere Vacuum Breal:er
Manufact�er �.. �u� S Siu �--
Modei Nt�ber L�� C�� 1 M I Locaud At �^�� �✓ � C.� c.. �.,�� ��..L 1'+'�7
Serial N�ber f���o U�/
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valvt Air Initt Check Valve
Ininal Test DGClosed 1 ; � osed Ti,¢ht Opeaed at Opened at _nsid
Tight Leal:ed ❑ �sid _�sid
RP-__psid .2. I
�;� o Did not Opea o Leal:ed �
�P�
aad
Materials
Used
Test ARu DC-Closed Closed Tight o Opened at Opeaed at _esid
Repair Tight ❑ Dsid _nsid
RP sid
The above is c.ertifiad to be true.
Firm Name� ��J G n� c c.� �c,e�C �f�u Certifiod Tester � �� l "��t,�r-J`-'
Firm !��� b 1 3 Z� Cert Teste No. 1J���Z 5 G� Date q• Z`�-��
�� r, cc� ,.,�. Ii.�io '7"� 1��5
(3auge # O I I 1 la`�i�
Date last accuracy tested (,�- "� `'' �y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy