2014_0916 C�iECK ONE:
IRRIGATION DOMESTIC FIREI,INE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAN�OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � ��.,- - ; < �1'-.
The bacldlow prevmtion assembly detailed below has beea tested and maiatained as required bv TNRCC
regulazions aad is cerdfied to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle e Pressure Vacui�Brealcer
� Double Chxk Valvc ❑ Amiosphere Vacuum Breal:er
� „
Maaufactiaer ' , giu
Model Iv umber _ Located At , ;' t �!a,+
;
Scrial Nimmbcr
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checi: Relief Valv� Air Inlet Check Valve
Inival Test DGClosed Closed Ti;ht o� Opcned at Opeaed at vsid
Tight d Leal:ed o osid �nsid
, RP-.�sid ,
Leal:ed a "' 4 Did not Open 0 Leal:ed O
�P�
and
Mataials
Used
Test After DC-Closed Closod Tight o ppened at Opeaod at �sid
Repair Tight o nsid _nsid
RP sid
The above is cetifiod to be true.
Firm Name ,r '�. ��, Cetified Testa �•;�. �,�,, �-� l
�
Firm Address � . ��•: � _����,� �.��� �`��� Cat Tester No. ' i`�`-� Date �"i�+ '�'�-�' �
�;. , � ��_ ;
Gauge # ! � � , -,
�
� i
llate last accuracy tested i i ;'-! } �-�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy