2014_0623 C�iECK ONE:
IRRIGATION_� DOMESTIC FIRELINE
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE: �� �J��.�� Ie�^ /J�►•
The bacl�low prevention asscmbly detailed below has bxn tested aad maintaiaed as required by TNRCC
re_suladons and is ceitified to bc operating within acceptable paramctcs.
TYPE OF ASSEMBLY
e, Reduced Pressure Principle e Pressure Vacuim�Breaker
� Double Check VaIve o Atmosphere Vacuum Breaker
,i
Manufact�er Ft�'J�[! Siu ..�
Model Number �a Located At �iC.��� b 8� � �Pi���f?�/�C.�C �
Scrial N�ber � ��� `rf�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check Valve Assembly
lst Checl: 2nd Checl: Relief Valve :�llir Inlet Check Valve
Inival Test DGClosed / Closed Ti�t Opcaed at Opened at nsid
Tisht `� Leal:ed o vsid nsid
p��� �-�S�d ,.�
� o �a noc op� o r.,�t:�a �
��
�
Materials
Used
Test After DC-Closed Closod Tight o Opmed at Opmed at __�sid
Repair Tight o nsid osid
RP sid
The above is certified to be true.
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Firm Name ��.5 Fi rf.�'n���!"�, .��'`�, Certified Testtt I�J'��4� /�-Q�2�cs�S
Firm Address 2_/_?��,/�%�- � �� (�I� Cat Testa No� � " Date —�3!
Gauge # QS[�����']
llate last accuracy tested l��j�a,.��1.�
White - Customer's Copy Yellow - City Copy Pink -Tester's Copy