2014-0317 (5) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE X
BACIQ�'LOW PREVENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REPORT
rr,�OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��� �� �e ��'K �
The bacl�low preveation asscmbly detailed below has beea tested aad maintained as required by TNRCC
reguladons and is cerdfied w be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressurc Vacui�Breaker
'� Double Check Valve o Amiosphere Vacuum Brealer
�/r9 t�S � �r
Manufactsaer Siu
� �/ ,5 C� li.�� /�
Model Ivumber � Located At
Serial Ni�ber � �u^��`G C ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check�alve Assembly
lst Cbeck �nd CLec.l: Relief Valve Air Inlet Check Valve
Initial Test DGClosed�� Closed TiP t,,� Opeaed at Opeaed at _nsid
Ti�t � Leal:ed ol.•ff ❑ �sid _osid
RP-_psid �
I,eal;ed o Did aot Opea o L,eal:ed D
�P�
and
Materials
Used
Test ARet DC-Closed Closed Tight o Opened at Opeaed at _�sid
Repair Tighi 0 flsid osid
RP sid
The above is certifiod to be t:ve.
Firm Name �c ��o�� l���` Catified Testa i�r Il c ri�����v�ru �
Firm Address ����-�jo� /�l �v0�x��� ��� Cett Testc No. �'�="�'`��,"�'� Date /�"-�—��
Gauge # J aJ ``� �Y�
7 � � -'y
llate last accuracy tested ' " �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy