2015_0225 C�IECH UNg:
IBRIGATION DU�dESTIC FTBBLINS
B�AGKP'LOW PREVENTION ASSEMBLY TEST AND MAII�T'ENANCE REPORT
NA�pF pWS: CITY OF COPPELL
PW5 I.I).#
LOCATIfJN Of SERVICE: �2c� I � . SC - `,, �
Tbe b�ci�a�v p�on a�mblY de�ed bclow bas baa �es�od and mai�iaed as required by TNRCC
re�ala�aod is aroified to bo op�ng ait6in aa�bk Pa�s-
TYPE OF ASSEMBLY �
e R�d Pr�ac Pt�p1e c P�V�Bre�aa
�� Daubk Chacic Valv�e ❑ A�ae Vacmmm B�
�1,
� �✓c�� Siu
Mod�el Number �`7`� LoCatod At �� �r,s f �iJ�'�� c�
s�x� �o s' r �� �- �f�+� ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BR`EAI�R _
Doebte C'Leck v alve Ass�mbly ,
lst C'lrecJc Znd C3ecjc Rd'ucf�+alve Air I�et t�d�val�e
Inicai Test DC-Closad Closod Tight � Opeoed at (�x'aod ac osid
�'� 3.� � � 3, �-° D�a ,��a
�� Did noc Opea o L�eabod �
�� O
��
aad
r�tacaials
Used
Teu ARrt DC-Closod C1o�T�ig� o �od� �� --�
� �� p _�Dstd _,Dsid
RP
'Ibe ab�o�e is asoGed u�be true.
Fum Name ���--�- �„`� �� Ca'ti5ed Tesoa �vzhe 1�� �,�-=
Firm A,dr�eas ��� � �'� C�rt.Te�ar Na �D� 6����Da�e=
�/�-� �Y, �����
c�� # o ��y��x�
nate�st a��ra�y t�t� 6-��. /�
White-Customer's Copy Ye]low -Gity (',opy Pinlc-Tester's Capy
C�iECK ONE:
IRRIGATION DOMESTIC FIRELINB �
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT'
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE: ��- � � L� . ��-�, b�� �
The bacl�low prevmtion assembly derailed below has been tested aad maintained as required by TNRCC
re_Quladons aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Rcduced Pressvrc Priaciple e Pressure Vacuimi Breaker
Double Chxk Valve o Atmosphcre Vacuum Breaker
Maaufact�uer tii✓✓a'�� Siu r��
Modei Ivumber ��`-�- Located At Y�--�� � �v,--� �,
���- Sa � 5-f��l��--�' -� SC�. �c..,�..
Serial Nimmber
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAKER
Doubie Check v alv�Assembly
lst Check 2nd C3ec1: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti,Qht � Opened at Opeaed at osid
Tight Z,.� t$' I.eal:ed o �sid osid
R.P-__psid
I,�;� O �°� Did not Opea O Leal:ed O
�P�
aad
Mataials
Usod
Test ARer DC-Closed Closed Tight o Opened at Opeaod at .�sid
Repair Tight a flsid nsid
RP sid
The above is cerdfiod to be t�ve.
Fi:m Name �r t= �,•� �i'as Certifiod Testa /��t v�n����, ��^'
Firm Addr�ess �a `�`I�7 Cett Testa No.�Py�',' ��S vl Date z._L s_i�
(�✓� , -7S1L8
(3auge # �vq�S'�'
llate last accuracy tested �- /v- /�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy