2014_1008 __ ._
C�IECK ONE:
IRxIGATTON DOMESTIC FIRgLINg' X
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: �states of Coppell 1007 Indenendence
The bacl�low prevenrion a5sembly detailod below has been tested aad fi�La�^ed as required bv TNRCC
reg�lanons and is certified to be operating withia accrptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciple ❑ Pressure Vacu�Breaker
�3 Double Check Valve o A�ospherc Vacuum Breaker
Manufactiaer �2xS Siu �,n
Modei Ivumber o�OD�1, Located At a''J°1 �-� �r"'h.1 '
Serial N�ber � �I O� '
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLTUM BREAI�R '
Doubie Check L'slve Asaembly
lst C3eck 2nd Cbecl: Relief Valve Air Ialet Check Valve
Inival Test DC-Closed losed Ti,ht Openod at Opened at osid
Tight ,, (p Leal:cd ❑ �sid _Tnsid
RP-_Fsid �,v
Leal:ed o Did not Opea o Leal►ed o ,
aad� �� � ��
Mat�eriats '
. U�
Test Aftzr DC-Closed Closed Tight o Opened at Opeaod at __nsid ,
Repair Tight ❑ _nsid osid ;
RP id
The above is catified to be true. r- ''�
Fitm Namel-AFire&Domestic me�''t�ng Cettifitrl Tesur I
g�p�s Po Box 7 9 5 4 8 Cerrt Testc No.BP o o i s 3 s 5 Date �
Fort Worth Tx 76179
Gauge # 06070576
Date Iest accuracy tested 12/3/13
White-Customer's Copy Yellow -City Copy Pink-Tester's Copy