2014_0819 C�IECK ONE:
IRRIGATION__� DOMESTIC FIRELINE
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: d�t.�)�.a�u�
The bacl.-tlow preveation asscmbly detailed below has beea � mainfain� � nq� bv TNRCC
regulations aad is ccrdfied to bc operating within acccptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressurc vacu�Breaker
1� Double Check Valvc ❑ Amiosphere Vacuum Brealer
Manufacturer �``' � Sizc ��tG�
Model Number g s� Locaud At r�
Scrial Nimmber ��i7 fl �`7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Checic Va1ve
Initial Test DGCloscd Z�� Closed Ti� �Q Opened at Opeaed at nsid
Ti�t J� Leal:ed ❑ nsid _nsid
R.P-_psid
Lcal;ed o Did not Opea o Leal:ed �
�P�
aad
Mataials
Used
Test Af�er DC-Closed Closed Tight o Opened at Opm�at _osid
Repair Tight ❑ nsid osid
RP sid
The above is cectified to be true.
Firm Namc��l,#,� �a��c� St/A . Catified Testa ` �
Firm Addr�ess ZD 1�2- �,�� Cert. Tcsta No. 2 � Date 8-�`I-��
�f.�l /J �ZIo��
(�auge # / ! O! � `�O �?
llate last accuracy tested 2— �—�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy