2014-0620 (6) C�IECK ONE:
IR1tIGATION DOMESTIC FIRELINE �
BACI4Z.OW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE:��'1.SL- f 1`�G 1`a/�U C J✓.� P Z.�J S ►=r r�N v r �-
The bacl.�tlow preveation assembly detailed below has been tested aad maintained as required by TNRCC
regulations and is cerdfied to be operating within ac,ceptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacu�Breaker
�'` Double Chcck Valve � Am�osphere Vacuum Breal:er
Manufacaaer 1 � e � k- ��••s Siu �
Model Nimmber � � '� 1�,� Located At �f a 4 ��' �`�✓��- c ,J� ��/c/S
Serial N�ber � �� ��� b
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed � �° losed Ti�t Opeaed at Opeaed at osid
Tight Leal:ed o nsid _osid
R.P-_psid y , Z-
�;� p Did not Opea o Leal:ed �
RePairs
aad
Mataials
Used
Test After DC-Closed Closed Tight o ppeaed at Opeaed at �sid
Repair TighL � �sid nsid
RP sid
The above is catifiod to be t:ue.
Firm Name i-�')Ur`-'�'..' ` r(� �� r ��"-f� �;�,�,''�trtified Tcsta ��� L�.Y.� �{"�*_��.!`��,.�,�"�� ,� -
,;, � � _ „
Firm Address � �'% �>>� '� ~' � ��-� �� � Cat Tester No. ���E��:�,��`�� Dace >�����=-��w
� �
�,.�� ' �f b�1 ti ��k f ,��= 3 ��
;
Gauge # ��� � � �' ' ��
� Date last accuracy tested � E��`� �� ;��`= �r� �
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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