2015_0121 C�IECK ONE:
IRRIGATION ,,/ DOMESTIC FIRELINE
BACIC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� v w��, �� �-,e C �-
The bacl�low prevtntioa assembly dctailed below has beea tested aad ma�nta�nCd as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressure Vacu�Breakez
� Doubla Check VaIve ❑ Atmosphere Vacuum Brea�er
� �
Manufactiaer �'c �E:.u Siu �`7
Model Number X � `� Loeated At M��'�� e�s �` ��.,� c i,.! c�c �, k c.
Serial N�ber �'�-- g 3 �' �� 3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Cbeck Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Z- rSb Closed Ti,�ht Opened at Opeaed at nsid '
Tight Leal:ed o __nsid �usid
RP-__psid � `�
�;� ❑ Did not Opea o Leal:ed O
RePairs
and
Materials
Usod
Test Aft,et DC-Closed Closed Tight o Opeaed at Opme�at _osid
Repair Tight o esid _osid
RP sid
The above is certified to be true.
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Firm Name ��"� ��'�� �' ��-� �s r �`���` ���``-Certified Teste � 1 k �'f� `� X� �T . '..._
Firm Address ' 1 � �'� .�.�%� � � � ' �—
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=�� � ' '1 Cert. T�No. Date - Z ' -�j
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P
llate last accuracy tested �s' �'�'t-' ��� ~/f
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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