2014-0317 (8) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI4'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATTON OF SERVICE: 10'S �1'��ID�
'Ibe bacl�low preveation assembly detailed below has beea tested aad maiatained as requircd by TNRCC
reguladons aad is catified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacu�mm Breaker
'�C Double Chxk VaIve o Atmosphere Vacuum Breaker
r/
Manufact�uer /`c!�« S� �
Model Number � 52�� Locaud At /`���c��
Serial Nimmber ���'�/G/
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSiJRE VACUUM BREAKER
Double Check v alv�Assembly
lst Cherk 2nd Chec�: Relief Valve Air ldet Check Va1ve
Inival Test DGCIos Clos�d Tight 1� Opened at Opeaed at osid
Tight �� � Leal:ed� �' o _nsid _osid
RP-_psid
�;� ❑ Did not Open 0 Leal:ed J
�P�
and
Materials
Usod
Test After DC-Closed Closed Tight o ppeaed at Opmad at __nsid
Repair Tight ❑ �osid �osid
R.P sid
The above is certified to be tive.
Fiim Name �C T���� J i�►' � Certified Testa /��r��' ��('✓��/��'i-
Firm Addrass �"�. �a y �y� �'�����. T'� Cert Tesur No. ��r'l�i�T/�� D� !/-:�f
Gauge # l�l��'�/���
llate last accuracy tested i����f
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy