2015_0202 (5) �L6 � � �'�
C�IECK ONE:
IRRIGATION� DOMESTIC FIRELINE�
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CIT OF COPPELL
PWS I.D.# / � �it�r�C� ��
LOCATION OF S�RVICE: � O �c�, � ,���7
The bacl�low preveation assembly detailed below has beea tested aad ma�nta�n� � nq�� bv ?NRCC
reguladons aad is certifi�d to be operating within ac,ceptablc paramcters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principlc � Pressurc Vacu�Breaker
�' Double Chxk V ve o Atmosphere Vacuum Breal:er
Maaufact�aer Siu �/
Model Number O�C� / � � Located At C o � I��T
Scrial N�ber ���o o� L�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACU[JM BREAI�R
Double Check Valv�Assembly
lst Check 2nd Checi: Relief Valve !1ir Inlet Check Valve
Inival Test DGClosed Closed Ti;ht Opened at Opened at nsid
Ti�t Leal:ed ❑ �sid __osid
PG y y �__ps�d
Leal;ed ❑ '° Did not Open o Lealced �
�P�
and
Materials
Used
Test Af�r DC-Closed Closed Ti,Qht o Opeaed at Opeaed at _esid
Repair Tighi � nsid __nsid
RP sid
The above is certifiod to be true. � ��
�-
Firm Name �P�� /�'.`r� /"o. CertiSod Testa �
Firm Address�v �� �Q`� W������� Cert. Testr�No. 60 3�'.3 Date�1��
7S`/G S
Gauge # �3�� Q� �
llate lsst accuracy tested / -2 ��
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