2014_1008 ___ _._
C�IBCK ONE:
IRItIGATION DOMESTIC gigg�g' X
BACi�'LOW PREVENTION ASSEMBLY TES'T AND MAINTENANCE REPORI'
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: Estates of Coo�ell 1007 Independence
T3e bacl�low prevention assembly detailod be3ow has been tested and maintained as required by TNRCC
reguiations and is cerufiad w be operating withia accrptable parameters.
TYPE OF ASSEMHLY
C Reduced Pressure Priaciple e Prossurc Vacu�Breaker
�, Double Check Valve ❑ Amoosphere Vacuum Breaker
Manufactiaer �-�S Siu ( u
Modcl Ivumber �4� u� Located At �� �-+��✓'�-1
Serial N�ber d l�'�-(�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VAC[TiJM BREAI�R '
Double Check Valve Asaembly '
lst C3eck 2nd Cbecl: Relief Valve Air Inlet Check Valve '
Inidal Test DGClosed losed Tight Opmed at Opened at osid
Ti�,ht �.�v Leai:od ❑ _osid ��sid ',
R.P-_psid a `f �
Leaked o Did not Opea ❑ Lealced � �
g�� i
aad � � �
MateriaLs
. U�
Test Aftet DC-Closed Closed Tight o Opened at Opeaod at _T sid ;
�81T T1� � DSId DSld
�
R.P sid '
The above is c�ectifiad to be�ve.
� �
Fi[II1 N�C1-AFire&Domestic mPG�"t;ng CeRified Testa Corbin Mover I
Fi�an Address Po Box 7 9 5 4 8 Cert.Te�No.BP 0 015 3 8 5 Date � g
Fort Worth Tx 76179
Gauge # 06070576
Date last accuracy tested 12/3/13
White-Customer's Copy Yellow -City Copy Pink-Tester's Copy
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