2014-0317 (13) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE ✓
BACT�LOW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT
N�OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �h� �fel,v��� �k��c�
The bacl�low prevmtion asscmbly dctailed below has been tested aad ma�ntain� � � bv TNRCC
regulations and is ceraified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle e Pressurc Vacu�Breaker
� Double Check VaIve o Atmosphere Vacuum Breaker
�t �
Maaufacuaer ��-� Siu
Model Number /���� Located At �� C o�r.Q.� .'� �Ur�t�.GT
Serial Nimmber ��� ��� ��-
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VAC[TUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Chec�: Relief Valve Air Inlet Check Valve
Iniaal Test DGClosed Closed Ti,�ht � Opened at Opened at osid
Ti�t � Leal:ed ❑ nsid �osid
RP-� d� si
I,�;� o y- � Dia noc Opea o Leal:ed o
�P�
aad
Mataials
Used
Test After DC-Closed Closed Tight o Opeaed at Opmod at �sid
Repair Tight ❑ �sid _osid
R.P sid
The above is certifiod to be true.
��,� � �ll�
Firm Name � o v� �i� ��� Certified Testa � � �U���
Firm Address:�n R:�Y �7 i7, ��'�n.����ti��,'1� Cert Teste No.i3�?bD"7CZ Date 11:1�L�,
Gauge # �6(7�� �7� (�
Date last accuracy testea �"" -'�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy