2015_1204 C�iBCK ONE:
IRRIGATION � DOMESTIC FIRELINE
BAC�'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT'
NAI�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: "/ `-t� �;/��� ��
Tbe bacl�low preveadon asscmbly detailod below has beea tested 3ad ma�ntain� � nq�� bv TNRCC
reguladons aad is cercified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacu�Breaker
� Doubla Check Valve o Amiosphere Vacuum Bnal:er
Maaufact�er ��� Siu �G �
� ����u��
Model Number � � Located At ���`'�1
s�;���ba �-D , 16 �7 �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check �nd Checi: Relief valve Air Inlet Check Valve
Inival Test DC-Closed Closed Ti.r�ht Opened at Opened at �osid
Ti� Leal:ed ❑ nsid __osid
RP-__psid (,�
L,eal;od 0 Did not Opea o L,ealced o
�P�
and
Mataials
Usod
Test Aft,er DC-Closed Closed Tight o Opeaed at Opeaod at �sid
Repair Tight ❑ Dsid nsid
RP sid
The above is certified to be true. -
�1�� � � � �/4-��9
Fum Name tO���r'�- ��� Cert�fied Testa �
Firm Address 3��I ��I��'" Cat Tester No.�P�3�S_Z Date ��r�'��
Ga� � C��-�/L�� 3 �2 6��
llate last accuracy tested ��'-���f
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy