2015_0226 C�IECK ONE:
IR.RIGATION �` DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 'l; , _; �l ,Y�,;,?',.;�. J,,',
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The bacl-flow prevtation assembly detailod below has beea testcd aad maintain� � nq�� bv TNRCC
reguladons and is certified to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressurc Priaciple C Pressure Vacu�Brealcer
� Double Check Valve o Atmosphere Vacuum Breaker
,:
Maaufactzaer _ Siu i
Modei Iv�ber �� Located At - � �'< <: � _<,;,
Serial Nimmba � - '
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Ininal Test DGClosed Closod Ti,Pht �' Opened at Opened at _,_csid
d Leal:ed ❑ �sid osid
� - `` �sid �
�;� ❑ Did aot Opea O Leal:ed �
�P�
aad
Materials
Used
Test After DC-Closed Closed Tight o Opeaed at Opmed at __�sid
Repair Tight o osid _osid
R.P sid
The above is catified to be true.
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� Firm Name �,.1-�-�• - �r�< � � Certifiad Tater r�;�� �._ �,�s �',� '
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FirmAddress + ,;:` _7 = ��'' -- Cert.TestcNo. �%1`1" Date ���
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(3auge # i� j � ;�:
Date last accuraey tested i f t�;�;�;
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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