2016_0211 C�IECK �NE:
IRRIGATION�_ DOMESTIC FIRELINE
BACIQ�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
N�OF Pws: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE: �� I ��i%�-i�,ti���- �;�`�
The bacl�low preveation asscmbly detailod below has beea tested aad maiatained as reqaired bv TNRCC
re„sulations and is cctified to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
c Reduced Pressvre Principle e Pressure Vacu�Breaker
� Double Chxk Valve ❑ Atmosphere Vacuum Breaker
,�1 t�
Manufacn�rer �cJ� K�i�v� Siu �
Model Nt�ber '� �p Located At _ _�����- y��`�'�=
Serial N�bcr /# r—J�� l��b�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VAC[TUM BREAI�R
Double Check Valve Assembly
lst Checl: 2nd Checl: Reiief Valve Air Inlet Check Vaive
Iniaal Test DC-Closed Closed Ti;ht � Opened at Opened at �esid
Tisht 2<<f � Leal:ed nsid _osid
R.P•_psid � �f'
LcaI:od o Did not Opea O Leal;ed J
�P�
and
Mataials
Usod
Test AR,er DC-Closed Closod Ti,Qht o Opeaed at Opmed at _osid
Repair Tight o osid nsid
RP sid
The above is certifiod to be true.
Firm Name!'141�n!`/?��`�jv �L1 Certifiod Tatte �nJ C.�i�'�"t���lK�i�
Firm Address 2 f�Z„� ra� /� �� Cert Testa No. t �3� Date —(!�!
�e w ,,�i TiC Zloz.o_�
c3auge # /l01 C?�D�°i
llate last accuracy tested /- /S-J{s
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy