2014-0317 (2) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � �� ��P'� 1�d �' �
The bacl�low prcvmtion assembly detaile� below has beea tested aad maintained as required by TTIRCC
regulations and is cerufied to bc operating within acr,eptablc paramtters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle e Pressurc vacut�Breaker
�L Double Check Valve o Amiosphere Vacuum Breaker
� �i
Maaufact�er L'�'��� ¢�s Siu
Modei Number ����r�� Locaud At ,5��� �'�'��P`� � yu c'��`�
� _ �
Scrial Nimmba �� 7 �,''
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Vaive
Inival Test DGClosed Closed Ti�t ;� Opened at Opened at nsid
Tight /> �' � Leal:ed /.fS o _�sid _osid
R.P-_psid
I,�;� o Did not Opea o Leal:ed o
�P�
and
Materials
Used
Test After DC-Closed Closed Tight o ppeaed at Opeaed at �sid
Repair Tight ❑ �sid _,_osid
R.P sid
The above is cestifiod to be true.
Fiim Name ��rio r`� /=�it� Catified Testa �� /1� �����s9�y S
Firm Address r �?-�� � 7`t' 7 ���'�X�-T�-Cat Tester No.��'��o01�� Date�/-� /f�
Gauge # �'�G O�l/��G'
Date last accuracy tested � �� /y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy