2015_11213 C�IBCK ONE: /
IRRIGATION DOMESTIC FIRELINB�
v
BAC'I{FZ.OW��VENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATTON OF SERVICE:�J �YD�°'�a(e[�
The bacl�low preveation assembly detailed below has beea tested and maintaiaed as required bv TNRCC
re�ladons and is cerdfied to be operatiag within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressurc Vacu�Breaker
� ble Check Valve o Atmosphere Vacuum Breaker
� ,,
Maaufactsaer Siu
Model Number �S�� Located At �� V�4�t��� KJ�1 `�T V F,e�, ��(,D✓N�/
Serial N�ber � �-'~�D � �1�,o I �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst(yecic 2nd C7uc1: Relief Valve Air ldet Check Valve
Inival Test GClos 1 i o Opened az Opeaed ac �d
p � 0 __nsid _osid
RP- I•�id
�� ❑ 3•� Dia noc Opea o Lea1:e� �
�� ep�rd�
aad �1'e s� CaLk s
Mataials � ��
Used � , 3>
Test Aftet DC-Closed Closad Tight o Opcaed at Opeaed at _�sid
Repair Tight o nsid __osid
Rp 'd
The above is catified to be true.
Fnm Na�e�oe�er �'�e Pr��ccrievJ CatiiSed Tesee u�V�i�i�l f,P�►''ce
1 b',}Sl b!y�,�/,� !�� 1�.�/l�S�T"f� �7S'222� Cat Teste No.�3� / Date a '�
Firm�,dldre�s -
Gauge # ��r�D ��i2
Date last accuracy tested (o" � / '�,�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE (/
BACT�LOW Pi�VENTION ASSEMBLY TES?AND 11�1AIIVT�NANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: �� �Ow�N aD i�l�
The bacl�low preveation assembly detailod below has bem tested aad maintained as required by TNRCC
regularions and is certified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressurc Principle e Pressure Vac�nmi Bnaker
iz� Doub e Checic Valve o Atmosphere Vacuum Breaker
Maaufacnaer C G� Siu �/y p
J� , t �
Modei Number !)�� �'� Locaud At �� ��,�1 ,� �� �V�� N , ���N�ir
Serial N�ber � �)�0''7 ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUIJM BREAI�R
Doubie Check v alve Assembiy
lst Check �ad Cbec1► Relief Valve Air ldet Check Valve
Initial Test -Cl _ osed Ti ❑ Opcaed at Opeaed at _�id
1 �, p Leal:ed 0 �sid _osid
R.P- �sid
� a � ` 1 Dia noc opea o L� o
Repairs R�PIihC�cQ
� 'f�cS�coc�S .
u�a� �.� .�� .�y
r�c� Dc-ci� ci�a r,�t o o�a� o�a�c ��
Ropair Tighi o flsid __nsid
Rp sid
The above is certifiod to be true.
Firm Name /CB��}gr Ti'Irf 1�l°�rC�7e�A�V Cetified Testa /Jr,UIR�V ���•Y+��
F�1� ��. A�r�j,r. ���„2,.� Cert.Testc No�AOI 10��21 Date • '!J`
cg� � _lI�30 '��_
Date last accuracy tested b���"/�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy