2015_0812 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI4Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �7 "( ���� �T �J
The bacl�low przveation assembly detailed below has beea tested aad maiatained as required by TNRCC
regulations aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� �educed Pressure Principle � Pressurc Vacu�Breaker
�� Double Chxk VaIve o Atmosphere Vacuum Breaker
Maaufact�aer �� Siu
�/y ��
Model N�ber a � Locaud At ���-
Serial Nimmber �1�• Z Z� � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubie Check v alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Initial Test DGClosed losed Tight Optaed at Opened at _osid
Ti� Leal:ed o �sid __nsid
R.P-�psid Z
I,eal:ed o � Did aot Opea O Leal:ed �
�P�
and
Materials
Used
Test After DC-Closed Closcd Tight o Opeaed az Opea�at _�sid
Repair Tight o flsid _osid
R.P sid
The above is certifiod to be t:ve.
Firm Name,�/�}/U�I�2#� �2i� Catified Tester ��W�-� �j �N�Pr�'i'!
Firm Address�.��1 ��ip �� DI'�Cert.Testc No.�P�3�`S Z Date ��j Z'� S
Gauge # ��c./+Oj R�-L� ���� ��
llate last accuracy tested f�� Z �—1 �/
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy