2013-0620 C�iECK ONE:
IRRIGATION DOMESTIC (/' FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:��"15�--��c.�'�✓v� ���,� I � ` , �� I-- r �r�7���
The baci�low prevmtion asscmbly derailod below has bxn tested aad ma�ntain� � nq� by TNRCC
re_guladons and is certified to be operating within acr.eptable paramtters.
TYPE OF ASSEMBLY ,
e Raiuced Pressure Principle ❑ Pressure Vacut�Breaker
� Double Check Valv� a Atmosphere Vacuum Breal:er
Manufact�er ��c� � � Siu Z-
Model N�ber � 1 C��� M 1 Located At ►M c� t.i l� �!i� r h J �(C)c�
Serial N�ber �� 1 1 � 3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubie Check Valve Assembly
lst Cherk 2nd Checl: Relief r ai�e 4ir Inl�t Check Valve
Initial Test DGClosed z � Close�Tight Opeaed at Opened at osid
Tighi Leal:ed a �sid osid
RP-_,psid -Z . �
Leal:ed ❑ Did not Opea o Leal:ed �
RePairs
and
Materials
Used
Test ARer DC-Closed Closed Tight o Opmed at Opeae�at �sid
Repair Tight o nsid osid
RP sid
The above is cerdfied to be trua. �
_"t �
Firm Name `��i�J:�� $}?t':�' W�j t.� '.(����i C.� Cetificd Testa �-� "��. ����-��� ':r�-'f t'.r�
Firm Address ��'�'J� '����� � Cert. Testa No. ;` �',� Date �2?�t�-/
i°
_., ,q � _
? �,)Ln tlai,l v,Yi� i �� l�.-'� l J
� Gauge # �1 �� �, '� � � �
r,°; ;, t <?
llate last accuracy tested �� '' '
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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