2013-1119 (2) C�IECK ONE:
IRRIGATION DOMESTIC � FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 77S N �cN T� —T�' �A � �w
The bacl�low prevmtion assembly detailed below has bcea testod and maintained as required by TNRCC
re_sulations and is cerdfied to be operating within acceptable parametet�s.
TYPE OF ASSEMBLY
❑ Reduced Pressure Priaciple � Pressurc Vacu�Breaker
� Double Chcck Valve o Amiosphere Vacuum Breaker
Manufact�er
l�►� ,—�� s� � ��
Modei Number L�v-�`� n� I Locac�d At ����� �+�.� 1�y a2 E;� ,-�
Serial Nimmber DU(� d � I
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubie Cherk Valve Assembly
lst Check 2nd Chec]: Relief Valve Air Inlet Checic Valve
Inival Test DGClosed Closed Ti,pht �if Opened at Opeaed at osid
Tight 1�4 Leal:ed o �sid _osid
RP- �'�Dsid
L,�;� p Z+ � Did aot Open o L,eal:ed o
�P�
and
Materials
Used
Test After DC-Closed Closed Tight o Opeaed at Opeaod at __nsid
Repair Tighi ❑ osid ____,osid
RP sid
�
i
The above is certifi�to bc uue.
Firm Name!1 � � A���►'� ����"Crtifiod Testa ��F �t�`��/�'S
Firm AddRss �-2/l-�t r,�,� � 7��"�7 Cert Testa No. ,1��'z�3�`:�7 Date ��2 2 -/
Gauge # /rrUZ I�5 2 4'
Date iast accuracy testea J( -l� /`3
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy