2014_0922 r'`
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
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�� BACT�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAN�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �`l� �Ie� �<� � ?t
a
The bacldlow prevention asscmbly detailed below has bxa tested aad maintained as required by TNRCC
reguladons and is certified to be operatiag within acceptable paramcters.
TYPE OF ASSEMBLY
e ,� Reduced Pressvre Principle � Pressure Vacu�mm Breaker
m.�`� Double Check Valvc ❑ Atmosphere Vacuum Brea�er
Manufact�er ���i�`c� Siu �j�/ � -
Model Iv umber �''�t`� Located At ��.. ' ��� /
Scrial Nimmber `�� ,,=�`I��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI+�R
Double Check Valv�Assembly
lst Check 2nd Chec�: " 'ef Valve Air Inlet Check Va1ve
Inival Test DGClosed losed Ti�ht Opeaed at Opened at. ,� � ��nsid
Ti�t �.,� Leal:ed ,� �, 0 _�sid _osid
RP-_psid
I,eal;ed o Did not Opea o Leal:ed o
�Pairc
and
Materials � �
Usod
Test Aft,er DC•Closed Closed Tight o ppened at Opeaod at _nsid
Repair Tight , o �sid osid
R,P sid
The above is catifiod to be we.
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Firm Name �%�"&�� � Catified Tester A-�� �:��
Firm Address fi'' �;� �=`r>� �1��,,��� Cert.Testc No. �;,�'��'/Z Date `�`%
(�auge # .�a2 J.�,�`'�"�
llate last accuracy tested �'-�7� �3
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy