2015_0123 C�IECK ONE:
IRRIGATION� � DOMESTIC FIRELINE
_„�,.�..
BACI{F'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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LOCATION OF SERVICE: �� 1 f A.:�� � . � �i� . �
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The baci�low prevmtion asscmbly detaile� below has beea tested aad ma�nta�n� � nq� bv TNRCC
regulacions and is certified to be opera�ng within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Priaciple e Pressure Vacu�Breaker
� Double Check Valve ❑ Amiosphere Vacuum Breaker
Manufactsaer �� �;��` �°� S� �
,'`����_� Locaud At C�i�.C< ��.C
Modei Number �- �.:�
Scrial Nimmber }� ',�' � ii ,;% _
.
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly '" �
lst Check 2nd Checi: Relief Valve Air Inlet Checic Valve
Inical Test DC-Closed Closed Tight '� Opened at Opened at esid
Tight P � Leal:ed o Dsid osid
RP- L psid
I,�;� ❑ � Did not Opea o Leal:ed o
�P�
aad
Materials
Used
Test After DC•Closed Closed Tight o Opeaed at Opeaed at _�sid
Repair Tight ❑ osid osid
RP sid
The above is certified to be true.
Fi:m Name �• ���,��1�"�`�`,1���; _ Certifiod Testa �-�y���;-��P,A f_ � ���E��' �
Firm Address j,,,�r%� �`� `11.t�t:��ti '�� '-i����w�< Cat Tester No �i-' � �:;l i��� Date �-��
� 7 `�;.,,t;,:,t
, �
Gauge # �'�;i�''�, , ���i�' �",,
Date last accuracy tested i` ��-� �'�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy