2015-0130 (6) C�IECK ONE:
IRRIGATION DOMESTIC �l FIRELINE
BACI4'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
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LOCATTON OF SERVICE: � �C� t°'�'E'_ -C:-dc�Y�` �"}IC tyc��/ .
The bacl.-tlow prcvmtion assembly detaile� below has baa tesied aad mainta�n� � nq� bv TNRCC
regulanons and is certified to bc opera�ng within acceptablc parameters.
TYPE OF ASSEMBLY
C � Reduced Pressure Principle � Pressurc Vacuimm Breaker
:1r pouble Chcck VaIvc o Amoosphere Vacuum Breal:er
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Maaufactsaez ��"l�' �C``� Siu
Modei Number L�' C)C,� � 4 �.t�� Located At ��'t���" '���t..l���� 1�1��'"�� ��i��`
Serial Nimmber �� ��C��� _
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BRF.AKER
Doubk Check v alve Assembly
lst Cherk 2nd Checl: Relief Valve Air Inlet Check Va1ve
: Inival Test DC-Closed Closed Ti;ht � Opeaed at Opeaed at nsid
Tight Leal:ed o �sid _osid
RP-_psid
�;� o Did not Open O Leal:ed o
RePairs
aad
Mataials
Usod
Test Aft,er DGClosed Closed Tight o Opened at Opmod at _�sid
Repair Tight o Dsid __osid
RP sid
The above is certi6ed to be true.
Firm Name Y�i `�z�=3` K-�tr�r�.7'� ,�, CeRifiod Tester ��" ' �'F?r'� 1'�i�"-;I-,��r`�
, :c
Firm Address��'`��'1� �`-��t�`� ,� Cert. Tester No.#��1�-�7C��`�Date �-� -r�
!_�� �a,����,�1�`�!�'��7`x��-�r�.�t-i
Gauge # �� f C� I (:�"`')�-�
llate last accuracy tested � - �(� - ( �j
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy