2014-0317 (10) C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE
BACT�'LOW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � �� �J���'���' �
The bacl�low prevmtion assembly detaile� below has been tested sad maintain� � nq� bv TNRCC
regulauons aad is cerdfied to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressurc Vacui�Breaker
'� Double Chak Valve o Amiosphere Vacuum Brealer
ff� ?
Manufact�aer �,l✓� Siu /�
Modei Number � �'��� Located At ����'�%1
Serial Nimmber `•%'r1 ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
ist Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti,Pht � Opened at Opeaed at nsid
Ti�i / j� � Leal:ed /y� ❑ __,osid _osid
R.P-__psid �
�;� ❑ Did not Opea O Leal:ed o
�P�
aad
Mataials
Used
Test After DC-Closed Closed Tight o Opeaed at Opmed at _nsid
Repair Tight ❑ �sid _,osid
R.P sid
'Ibe above is catified to be t�ue.
Firm Name f�c�T�o r- t�'�'� _ Catified Testa �'��'` � �������
Firm Addtess �'�. lf�� 7 l% ���•r Cat Taster No.�`ca�oa�o T� Date 6�^'���
Gauge #��'����� �'
llate last accuracy tested 3`�����
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy