2015_0625 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACICF'LOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: ��O ��r>�; '`c�-� ,.^�
( lr "'�`
The bacl�low preveation asscmbly detailod below h� beea tested aad maintaiaed as required by TNRCC
regulations aad is certified to be operating within acceptablc paramcters. .
.� TYPE OF ASSEMBLY .
C �Rcduced Pressure Principle � Pressure'Vacu�Breaker
�/ Double Chxk Valve ❑ Atmosphere Vacuum Breaker
Manufacuaer ��1'ra Siu .�/`�� `
Modei Ivumber �.�.� Located At 1.,�.,, � `��..r_ ''�
Scrial N�ber ,� ����/'l����-� � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alv�Assembly
lst Check 2nd Checl: ef Valve Air Inlet Check Valve
Initial Test DGClosed Closed Ti;ht Opeaed at Opened at csid
TiQht Leal:ed ❑ �sid _osid
� R.P- a f nsid r, '� �
Leal;ed ❑ Did not Opea 0 L,eal:ed o
RePairs �
aad
Macerials
Used
Test ARer DC-Closed Closed Tight o ppened at Opeaed at �sid
Repair Tight ❑ �sid __nsid
RP sid
The above is certified to be true.
Firm Name �����'�/c;� Certifiod Testa ° ✓�,,
Firm Addc�ess �r� � �/iS�S .���-�;�'� Cert. Tester No. '� ��Date 6- � r.�
;x�/��,�.,�
Gauge # /:�/?,�',�� '
llate last accuracy tested �- .�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy