2015-0130 (5) C�IECK ONE:
IRRIGATION DOMESTIC •� FIKELINE
BACI4'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: I �C� �"��� i�C�� 1` �I�uJ�J .
The bacl�low prevtation asscmbly detailed below has baa tested and IIlr1IIla�ned as required by TNRCC
regulations aad is certified to bc operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressure Vacu�Breaker
� Double Chxk Valve o Amiosphere Vacuum Brea�er
� t
Maaufact�aer V�� (�� �� Siu
Model Number �-...� C�C��i� � � 1 Located At �v'Or�,�t' t'1aCc.��r r. ���' r��C'�`�'�r
Seriai N�ber � t��� � `�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check v alve Assembly
lst Check 2nd Checl: Relief�alve Air Inlet Checic Valve
� Inical Test DGClosed Closed Ti;ht Opened at Openod at osid
Tight Leal:ed ❑ nsid _osid
RP-_psid
�;� ❑ Did not Opea o Leai:ed �
�P�
and
Materials
Used
Test ARet DC-Closed Closed Ti,Qht o Opeaed at Opmed at _�sid
Rtpair Tight ❑ �sid nsid
R.P sid
The above is cadfied to be tive.
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Firm Name �"'`�i�;�-- , �°'��r" �:�� ��r�;' .�►���f Catifiod Testc � �-�''�l�r"� .�7 i_S��r'-�
.L� �rC .
,.-� �, ,---, ,-,-7 r� �
Firm Address¢.P"�I'� ���;=�,{�t-�� Cert. Tester Na�"��'�]'' ; � r(`i �Date -��
�.:1 :;
�t';�1�, �� v: � ��� , �-��.��:,�
(�suge # �,�'i c`�'"�f a�,,o
llate last accuracy tested�;7 � �- � �'"
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy