2015_0805 C�IECK ONE:
IRRIGATION�_ DOMESTIC FIRELINE
BAC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ' �'��
The bacl�low prevmdon asscmbly detailed below has beea tested sad maintain� � nq�� �v 'I'NRCC
regulations and is cerdfied to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
e/ Reduced Pressure Principle e Pressvre Vacu�Breaker
d Double Check VaIve o Atmosphere Vacuum Breaker
Maaufactsaer �f���1'd� Siu � ��Z,
Modei Iv�ber ��� Located At �'✓��-7��l/
Serial N�ber ��10 � ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air ldet Check Va1ve
Inival Test DGClosed Z�y Closed Ti.,,pht d Opened at Opened at nsid
Ti�t t� Leal:ed ❑ �sid __osid
RP-�sid
_� � I,r�1;ed a g Q Did noc Opea o Leal:ed o
�P�
and
Materials
Used
Test ARer DC-Closed Closed Tight o Opened at Opeaod at �sid
Repair Tight ❑ osid nsid
RP sid
The above is cerdfiod to be true. /���
Firm Name ow Catified Tesca ,f�I��Y.'l��i�Yl,��.�11
Firm Address �991�'Bsrton Gircle Cert. ?esca No. � Dace "s� 1�
o, 5035
(�auge # ' 02
�
Date last accuracy tested � ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy