2015_0928 C�IECK ONE:
IRRIGATION_� DOMESTIC FIRELINE
BACT4'LOW PREVENTION ASSEMBLY TEST AND MAII�I'ENANCE REPOR?
N.�iv�OF Pws: CITY OF COPPELL
PWS I.D.#
� , �/
LOCATION OF SERVICE: IS C1 y/lt T/���� C
The bacl�low prevmtion assembly detailed below has aad maiataincd as r�equired by TNRCC
regulations aad is cectified to be operaung within acceptable parameters.
TYPE OF ASSEMBLY
C/ Reduced Pressure Principle C Pressure Vacu�Breaker
��0" Double Chxk Valvc ❑ Amiosphere Vacuum Breaker
Maaufacuaer �f�e� Siu �/��/
Modei Nimmber � S� Located At ��Y9�C�` ��1'�
Serial N�ber �� �� 6� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Chec1: Relief Valve Air Inlet Check Valve
Inival Test DC-Closed �--3 Closed Ti� � Opened at Opened at �id
Tight Leal:ed ❑ �sid _�sid
RP-_psid
I,�;� o Did not Opea o Leai:ed o
�P�
and
Mataials
Used
Test After DC-Closed Closod Tight o Opened at Opeaed at _�sid
Repair Tight � �sid osid
R.P sid
The above is catifiod to be true.
Firm Name �'C ^�/�'�g�c�� Cetifiod Te.sce �"�� �Y`�-�'
Firm Address 0 ;Z D4 S� Cert Testa No,� �l3� � Date `�- 2�� /.S
Gauge # O�I,�/�J` 6
Date last accuracy tested ��-
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy