2015_0623 C�iECK ONE:
IRItIGATION DOMESTIC FIRELINB
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� � � L�:&�
�
The bacl��low prevention asscmbly detailed below � beea tested aad maiatained as required bv TNRCC
re_�ons and is ceraified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�e 'Reduced Pressvre Principle e Pressure Vacuimm Breaker
Double Check Valve o Atmosphere Vacuum Breaker
C'_s �
Maaufact�er } ���-!�� Siu -}/`/
� '�' wc/,..r ,�`
Model Number �`�.% Locatad At �
� Serial Nimmber �f�r�1.��'-� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ist Check 2ad Checi: 'ef Valve Air Inlet Check Vaive
Inival Test DGClosed Closed Tight Opened at Opened at esid
Tighi � � Leal:ed o _�sid _�sid
��l�-�5 RP-_psid � �,
�;� ❑ Did aot Opea o I,eal►ed � '
RePairs
and
Mataials
Used
Test Aft,et DC-Closed Closed Tight o Opened at Opeaed at _�sid
Repair Tighi o �,nsid _._,osid
� RP sid
The above is cerdfiod to be ttue.
,� ;
Firm Name �.-._�,�:. CatiSod Testa
1
Firm Address A� '�r �`i''' 7��� Cat Tester No. �'f�'7/�'',Y�(;'� Date - �� �``
4'"x✓'r.,.�?{,�� f 4 ...7fyr.v)i� .
'l�
�
Gauge # ���'r°';��:�;:_
llate last accuracy tested ��-�; �s; �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy