2015_0517 C�IECK ONE:
IR.RIGATION�/ DOMESTIC FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATTON OF SERVICE: � �3 S�I��'�C� /�1"
The bacl�low prevmtion assembly detailed below has been tested aad maintained as required bv TNRCC
regulations aad is ctrdfied to be operating within ac�eptable parameters.
TYPE OF ASSEMBLY
e Raiuced Pressure Principle e Pressure vacu�mm Breaker
,�2� Double Check VaIve o Atmosphere Vacuum Breaker
Maaufactsaer ���'�° Siu ���
ModelIvumber �� LocatedAt ��fd✓(� Is�
._.
Serial N�ber � O � 7� �� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assemb�y
lst Check 2ad Checi: Relief Valve Air Inlet Checic Valve
Initial Test DGClosed Closed Ti,,P.ht Opeaed at Opened at osid
Tight Leal:ed o �sid �sid
RP-.�psid
I,�;� o �� Did not Opea o Leal►ed �
�P�
aad
Mataials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaod at �sid
Repair Tight � �sid ___..,flsid
R.P sid
The above is certified to be true.
Gandara Irr�clfon � �� ,� J����
3901 C7ifton Dr. �� /�r-—
Fiim Name Dl,.�„�„�,�, Tx z��R� Catified Testa
Firm Address Cert. Tester No. ��� Date '-'/����
Vauge # C�s,v/.�l�.+4-c� `3I 2 C� ��
llate last accuracy tested �� �� '�f
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy