2015_0414 CHECK ONE:
IR.RIGATION �/ DOMESTIC FIRELINE�
BAC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L'I� � 1"i OUS�OrI ��.
The bac3�low prevmtioa assembly detailed below has ban tested and ma�nta�n� � nq� by TNRCC
regulauons and is certified to bc operatiag within acceptable paramcters.
TYPE OF ASSEMBLY
C/ Reduced Pressure Principle ❑ Pressure Vacuimm Breaker
�l Double Chxk Valve ❑ Amiosphere Vacuum Breaker
� " n
Manufacturer ��i�OC t �� Size l
,
Model N�ber 35� Located At M � 15.(,J, e.orner o f
Scrial Nimmbcr A����� ► ��� r
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check Valve Assembly
lst Checl: 2ad Checl: Retief Valve Air Inlet Check Vaive
Inidal Test DC-Closed Close�Ti;ht Opened at Opened at nsid ,
Ti�ht Leal:ed o nsid �sid ,
RP-�psid '
�;� ❑ Did not Opea D L�eal;ed o
RePairs I!
aad
Materials
Used I
Test Aftet DGCloscd Closed Tieht o Opened at Opmed at �sid
Repair Tight o osid osid
RP sid
The above is certified to be true.
Firm Name��� k`f'rb t YY��r,C�ertified Tester ��I'f'�1P�'? iS�
Firm Address�a�a� Cert.Testc No.i�P6rY'�37[S�Date `� �I �«
[„�w�s�� �e�fX75c�
Gauge # ��S�C'�)(�� q �
llate last accuracy tested � r�a - �'�j
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White- Customer's Copy Yellow -City Copy Pink-Tester's Copy ;
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