2015_0701 C�IECK ONE:
IRKIGATION DOMESTIC FIRELINE �
BAC'I�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �I� . `7�-�{.u�.�4Y
T��
The bacl�low prevtation assembly detailed below has baa ttsied aad mainta�n� � nq� bv TNRCC
reguladons and is ccrdfied to be operating within acceptablc parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacu�Brealcer
'�l, Doublc Chcck Valvc ❑ Atmosphere Vacuum Breal:er
Manufacuaer ��t l ���/�Y� Siu 1� ..
Modei Number ��� � Locaud At ��„�'f�'15i b� ���-��
Scrial N�ber N�� ����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Yalve Assembly
lst Check��'rj 2nd Checl:�,� �ef Valve Air Inlet Checic Va1ve
Inival Test DGClosed Closed Ti;ht � Opened at Opened at osid
Tight �t1 Lcal:ed o nsid _osid
R.P-__psid
I,�;�d ❑ Did not Opea o I,eal:ed �
RePairs
and
Mataials
Used
Test ARer DC-Closed Closed Ti,Qht o Opeaed at Opeaed at _osid
Repair Tight o flsid osid
RP sid
The above is cerdfied to be true.
Firm Name ��V�C ��E Cadfiod Testa l,�+1�� ���Y���
Firm Address���;?� d� � �* � 11�' Cat Tester No. ' 0 Date '��( I �7iS
(�suge # 11�'3���'�
llate last accuracy tested �,- r�" �'"�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy