2015_0512 C�iECK ONB:
IRRIGATION V DOMESTIC FIRELINB
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: _ �1 � 5 �rD�Y I S ��
The bacl�low prevmtion assembly detailed below has beea testod aad maintained as required by TNRCC
reguladons and is ce:tified to be operating within acceptable paramtters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacu�Breaker
� Double Check Valve o Atmosphere Vacuum Brealer
Maaufactiaer �I ��I Y1.S Siu � ��
Modellvumber ✓�� LocatedAL U�eross G11� �;�,m �33Ti�tr,�i5
Seriat N�ber � � a�`� Cp�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check�alve Assembly
lst Check 2nd Chec1: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti,,P.ht Opened at Opeaed at _osid
Tight �! Leal:ed ❑ nsid �sid
R.P-_psid
�;� o Did not Opea o Leal:ed o
�P�
and
Materials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opm�at _nsid
Repair Tight o nsid __�sid
RP sid
The above is certified to be true.
Firm Name�,►jQ�c3'►'1 Certifiod Testa ��015 ��I�,t,�ni�-
Firm Address °�01 5 CQdc� u i 1 I�1,7 SI�y Cert. Tester No.I�p��3 Date 5 —�2—�`S_
t�auge # ����o��-�
llate last accuracy tested q -l( -��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy