2015_0702 '3/(o �2$'fr�
C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE�
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.� � s �. �� � y ��
LOCATION OF SERVICE: ` �� �� �, -1 5����
The baci�low prevmtion assembly detaile� below has bcea itsted aad ma�n ain� � nq� bv TNRCC
rcgulanons and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principle ❑ Pressure Vacu�Breaker
`� Double Chcck V v ❑ Atmosphere Vacuum Breaker
3/y //
Manufactiaer �ci. Siu
Model Ivumber � � � � Locatcd At �
Serial Nimmber c�� � ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief r alve 4ir Inlet Check Valve
Inival Test DGClosed Closed Ti,�ht Opened at Opeaed at nsid
Tisht � Leal:ed ❑ _psid _osid
�� C��j RP-__Psia
�;� ❑ p Did not Opea O Lealced �
�P�
and
Materials
Used
Test After DC•Closed Closed Tight ❑ Opened at Opeaed at _nsid
Repair Tight ❑ osid nsid
RP sid
The above is certifierl to be true. �
Firm Name ec., c,. �` Catifiod Testa S
Fitm Address �� �6X /� �r/ ��"�'i Cert. Tester No. �i.3� 3 Date �� —��
�--� �s��5
�8�e ����0�3
llate last accuracy tested 7� - �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy