2013-1230 (2) C�IECK ONE: �'
; �� RIGATION DOMESTIC FIRELINE � �
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'BACK�'LOW PREVENTYON ASSEMBLY TEST AND MAINTENANCE REPORT '
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NaME OF PwS: CITY OF COPPELL
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` PWS I.D. # E
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LOCATION OF SERVICE: �.3D 1�� ��E?��n;� f C�..�.� K,�; ,
The bacl�low prcveation assembly detaile� below has beea tested aad mainrained as required by TNRCC
regulations aad is certi5ed to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
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�(' Double Chcck'�7alve ❑` .d,tma�sphere`Vac�uum�realter i , , �
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Maaufacuaer ���7� � Siu
Model Number �; l� Located At �-��n'� �<�w r, 61�Et r /►-�.�_�Pr.
Scrial N�mmber � �� ,3��o�
�DUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Cherl: Relief Vaive Air Inlet Check Valve
Initial Test DGClosed Closed Ti,Qht �d' Opeaed at Opened at osid
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RePairs
and
Materials '
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Test Aft,et DC-Closed Closod Tight o pp��at Qpeaed at �sid
Repair Tight o nsid __nsid
RP sid
The above is certified"to be true.
Firm Name���,(�;, ' �S r�ertified Testa � � �� � t� ��P 1
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Firm Address , } t?� Iv�� : Cert. Tester No. � ����Z I Date ,�
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Date ]ast accuracy tested 2. 3G ) j
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy