2015_0513 (2) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE �
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT'
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATTOIv'OF SERVICE: _ �" O / S- 1`o I/ /9-
The bacl�low preveation asscmbly derailed below has been tested sad ma�n a�n� � nq� bv TNRCC
regulations aad is certified to be operating within acceptable paramet�ers.
TYPE OF ASSEMBLY
e Reduced Pressiue Priaciple e Pressure Vacu�Brealcer
'� Double Check Valve o Am�osphere Vacu�Breal:�e
Maaufactsaer � " � ! � G j�P Siu �
Model N�ber � C� � Located At 5- ��' � '' `' I/�
Scrial Nimmber ��(� � � �7(�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed � Closed Ti t � Opeaed at Opeaed at _nsid
D
Tighi �' � Leal:ed �.� ❑ _nsid _osid
R.P-__psid
Leal;ed o Did not Opea D Leal:e� D
�P�
and
Mat,erials
Used
Test Aftet DC-Closed Closed Tight o Opened at Opeaed at �sid
Repair Tight ❑ osid _,_osid
RP sid
'Ibe above is cerafied to be true.
Firm Name ����o " ����� c Certifiod Testa /'�� /� e Gvi ��i�9�S
�,a.13� 7� 7 � �s
Fi�Address � ��x�1� Cat Tester No. I3/�o 0 0 0 l� D� 5/3 -
Gauge # ��� `l! � 9�
llate last accuracy tested 3 ��' ��-S
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy