2015_0220 C�IECK QNE:
IRRIGATION V DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��Z ��L� L9-r�1 d
The bacl�low prevmtion assembly detailed below has baa tesud and maintained � required by TNRCC
rcgulanons and is certified to be opera�ng withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressurc Vacui�Breaker
� Double Chcck Valve ❑ Atmosphere Vacuum Breal:er
Manufacturer �bc.� Siu 3 �U' ��
Model Ivumber g�D Locatcd At -�
Scrial Nimmber 1��rl � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Dot�h�s,Check v alve Assembiy
lst Check �nd Checl: Reiief Valve Air Ialet Check Valve
Inival Test DGClosed 2•3 Closed Ti� �t ,� Opcned at Opened at nsid
Tidit Lcal:cd ❑ nsid osid
RP-_psid
I,�;� ❑ Did not Opea o Leai:ed o
�P�
aad
Materials
Usod
Test After DC-Closed Closad Tight o ppeaed at Opeaed at nsid
Repair Tighi o nsid osid
Rp sid
The above is cerdfied to be ttve.
Firm Name �LI� ��(� tzl.►z. S✓�Cerdfied Testa
Firm Address ?� �- Cert. Testa No. �'�v Date 2 -Zv -� S
�c� •J -t-�t. �ZG zoj
(3auge # 1 �ro l O �O q
llate last accuracy tested �-2Z -�S
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy