2013-1120 C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE
BACIQ�'LOW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: C� ( �1�C � � A��
The bacl�low prevmtioa asscmbly detailed below has bcea tested and maintained as required by TNRCC
regulations aad is cerdfied to be opera�ng within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principle ❑ Pressure Vacmmm Breaker
d�; Do le Check Valve o Amiosphere Vacuum Breaker
Manufact�er Siu � <<
Modei Number v� �m�J Located At � ^
Serial Nimmber ����� ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Cbeck Valv�Assembly
lst Check 2nd Chec1: Relief Valve Air Inlet Check Valve
' �al T DC-Closed Closed Tight o Opened at Opeaed at nsid
Tight � Leal:ed o nsid _osid
R.P-_psid
Leal;ed o Did noc Opea o Leal►ed �
�� , `l�iV�L. � �
Materials
Usod
Test After DC-Closed Closed Tight o Opeaed at Opeaed at _�sid
Repair Tight ❑ nsid _,osid
RP sid
The above is cerdfic�to be true.
- r . �
Firm Name � Certifi�Testa [ I
Firm Addness � � Cert. Testc Na � Date �� �3 I�
Gauge # � ��
llate last accuracy tested �� � ��(
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy