2014_0714 C�IECK ONE:
IR.RIGATION DOMESTIC �� FIRELINE
BACT�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
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LOCATION OF SERVICE: �� (t- /��` `�- �� �s`:4 y'
The bacl�low prevmtion assembly decailed below has beea tested and maintained as required by TNRCC
regulanons and is certified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciple C Pressurc Vacu�Breaker
_ _:___ � _ Double Check Yalve __- - - o Atmosphere Vacuum Breal:er
. %y ��
Maaufact�uer ��i� Siu
Modei Number G�l_` '% i��1 l -� ���T Located At �;;�r ., `� �` ,. /��r'a`T, � ,.
s«ial Ivumber �� c ;7 �//
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAKER
Double Check Valve Assembly Qv2
lst Check y . � 2ad Checl: Z •Z Relief Valve Air Inlet Check Valve
Ininal Test DGClosed Closed Ti�ht e' Opened at Opened at nsid
Ti�t et Leal:ed ❑ �sid _osid
'� RP•__psid
�'`�f+ �` I,�;� o Did not Opea O Leal:ed �
�P�
and
Materials
-__ . _ Uszd- _. _ .. �
-
Test After DC-Closed Closed Tight o Optaed at Opeaed at _�sid
Repair Tighi o �sid __..,osid
RP sid
The above is cerdfied to be true.
,/, , r�-,��n :5�k ,�; k ��� c�s�a T� �`fj� -��� `
Firm Name �r� �
Firm Address i i►��c t'%r,�/ .��r ���"'�`��' Cert. Testa No. ��` �'-' ��'�'' Date �-=��'"`1
��//��4 7� 7'z_?�t�'
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Gauge # t '%ii� 2 � �
llate last accuracy tested 7- `�- ��'�/�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy