2014-0317 (3) C�IECK ONE:
IRRIGATION_�_ DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��'� ��' P����
The bacl�low prevention asscmbly derailed below has been testod aad maintain� � nq�� bv TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressvre Principle ❑ Pressure Vacu�Breaker
� Double Chcck Valve o Amnosphere Vacuum Breal:er
l/
Maaufactiaer �ii'9 f f Siu �
Model Number ��' ��� Located At � � �.o`'�`r" �% i�'�����c, �
sc�ia�N�ba � � �s` �3.�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check 2nd C3eck Relief valve Air Inlet Check Valve
Ininal Test DGClosed Closed Ti�t � Opeaed at Opened at osid
Ti,ht 1� y :'�7 Lcal:ed j��S ❑ _flsid _osid
RP-_psid
I,eal;ed ❑ Did not Opm o Lea�;ed �
�P�
and
Materials
Usod
Test ARet DC-Closed Closed Tight o Opened at Opeaad at �sid
Repair Tight ❑ osid __nsid
R.P sid
T'he above is cerafied to be true.
� � f/�Cr �r/!� C�� ��/r1��, s
Firm Name / � �c�� Certifiod Testc
Firm Address ����•�°� 79 7 L!/��X,� �� Cert. Tester No. f�%cs cc 7�'-� �� l�����`r
Gauge # �i G�i�// 7 ��
llate last accuracy tested � ��-���
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy