2014-0620 (8) C�IECK ONE:
IRRIGATION DOMESTIC � FIRELINE
BACI�7.OW PREVENT'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �/4tSC-JN��rr.�, C.�.,,� I Z��' S 1'✓�c��L��'
The bacldlow prevmtion assembly detailed below has bxa tested aad *++a�nCain� � nq� bv TNRCC
re_�ulations and is cerdfied to be operating within acceptablc paramcters.
TYPE OF ASSEMBLY
C Reduced Pressvrc Principle C Pressurc Vacu�Breaktr
� Double Check Valve ❑ Atmosphere Vacuum Breal:er
Maaufact�uer % �� �C Siu �-
Modei Number � `' f h 1 Located At M r �r� ✓� ���� � �� �� �d�.
Serial N�ber 2� �� ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valv�Assembly
lst C3eck �nd Checl: Relief Valve Air Inlet Checic Valve
Inival Test DGClosed Z.-� losed Ti;ht Opeaed at Opeaed at osid
Tight Leal:ed o nsid osid
R.P-_psid Z �
I,�;� ❑ Did not Opea O Leal:ed �
��
and
Mataials
Used
Test Aft,er DC-Closed Closed Tight o Opeaed at Opeaod at �sid
Repair Ti,Qht o osid nsid
R.P sid
The above is certified to be true. .. ,
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Fum Name i�1`������,� ,'`; ���� f :��1 t�,;�,1, Certified Testa � r
;
Firm Address� ��l�')��:x �''�f �>,�_ � Cert. Tester No. �, `' `"� Date �►•�`z � ►`�
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��i 1 ,�1 uF� �,'( t ��, ,_�7� %a ".� ,,
�i81lg@ � � l• `�'i '��' �
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Date last accuracy tested � ���� �� ��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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