2014-0317 (6) C�IECK ONE:
IRftIGATION DOMESTIC FIRELINE �
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATTON OF SERVICE: � o� ��� ��a�Z+
'Ibe bacl�low preveation assembly detailed below has beea tested aad maintained as required bv TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciple ❑ Pressure Vacu�Breaker
� Double Check VaIve ❑ Atmosphrre Vacuum Breaker
3
Maaufacaaer �� � f Siu ��
Modei Number d� 7 � � Located At �'_ �� v�� I�
�� � ? � �
Scrial N�ber
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Checic Va1ve
Inival Test DGCIos� y Closed Ti�t 1� Opened at Opened at nsid
Tight � Leal:ed -�o Dsid __osid
RP-_psid
I,�;� o Did not Opea O Leal►ed �
�P�
and
Mataials
Usod
Test ARer DC-Closed Closed Tight o Opeaed at Opeaod at �sid
Repair Tight � �sid nsid
RP sid
The above is cvdfied to be true.
Fi:m Name A��o r" �'/��� Catifiad TestQ �� �c lG'��/���'s
Firm Address ��� �`' Y 7 � 7 �f�X p Cert. Testar No. �/f�o�o 7 G`� Date � _;a �-0�
(=suge # ��D�!/ y y�
Date last accuracy tested � �� 7 r��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy