2015_0812 C�iECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �> � �2 ,�� 7rtT_ �
The bacl�low prevention asscmbly decailod below has baa tested aad maintainod as required by TNRCC
regulaaons aad is cerdfied to be operaung wit6in acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressurc Vacu�Breaker
J� Double Check Valve � Amiosphere Vacuum Breaker
Maaufactiaer �j��G?� Siu � <`1
�
Model Number � � Located At "��"'� `'��
Serial Nimmber � � ZZ� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check v alv�Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Initial Test DGClosed Closed Ti,�ht Opened at Opened at osid
Ti� eal:ed o �vsid _osid
RP-�psid
� ❑ Z3 �a noc o� o t.�:�a �
��
�
Mataials
Used
Test Aftet DC-Closed Closed Ti,rht o ppeaed at ppeaed at _�sid
Repair Tight ❑ �sid nsid
RP sid
'Ibe above is cerdfied to be true.
Firm Name(��DI�2f� ��- Certifiod TaSta �'C��(�eJa i� O�D/�-2-1�
Firm Address 3�D I C�d F7v�ditCert. Tester No. ��Z�3�,SZ Date �-�2..���
(�suge # C�i�-�3(l�C� ��Z� �
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy