2015_0211 (2) C�IECK ONE:
IRRIGATION� DOMESTIC FIRELINE
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE: ��� �� ��P��
The bacl�low prcveation asscmbly detailed below has bxa testcd and maintained as required by TNRCC
ragulauons and is certified to be operating withia accrptablc paramcters.
TYPE OF ASSEMBLY
c - Reduced Pressvrc Principlc � Pressure Vacu�Breaker
� Double Check VaIve ❑ Amiosphere Vacuum Breal:er
Manufacnaer �d���' Siu '7�� � �
Model N�ber � �!� Located At � /�`���—
Scrial Nimmber
� l� "(� � �� �� G
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DGClosed *f�,a Closed Tight Opeaed at Opened at vsid
Tidit Lcal:cd 0 �sid osid
RP-_psid
I,�;� p Did not Opea o Leal:ed �
�P�
aad
Materials
Used
Test After DC-Closed Closed Tight o Opened at Opeaed at _�sid
Repair Tight o �sid osid
R.P sid
The above is certifiod to be true.
Fum Name Cercified Tata f� r��J !�/� ����
Firm Address�1���. 1-�.- Ccrt.Tcster No. l� Date� �— –�
�
�� ���
cguge #
llate last accuracy tested r' Z 7—�./
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy