2016_0520 C�IECK ONE:
IRRIGATION_�_ DOMESTIC FIRELINE
BACI�'I�OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE: ��� ���/k'�-��
The bacl�low preveation asscmbly detaile� below has bxa iesied 3ud ma+IIia�f+ed as required by TNRCC
reguladons and is ccrdfied to bc operating within acr.eptable paramcters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle C Pressure Vacu�Breaker
� Double Check Valve ❑ Amiosphere Vacuum Breaker
Maaufact�er ���{`' Siu � ��
-T
Model N�ber �'�17 Located At ���� �Get��.�, �,ca _
Serial Ni�ber �v�g��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAKER
Double Check Valve Assembly
lst C3eck 2nd Checl: Reiief Valve Air Inlet Check Va1ve
Iniaal Test DGClosed Closed Ti;ht d Opeaed at Opeaed at nsid
Tight � Lcal:ed ��� o nsid osid
RP-�sid
�;� ❑ Did not Opea O Leal►ed o
�P�
and
Mataials
Used
Test AR�er DC-Closed Closed Tieht o Opened at Opeaed at _nsid
Repair Tight o osid osid
R.P sid
The above is certifiod to be true.
Firm Name Catified Testa �c� �
Firm Address �0� Z � Cert Tester No. � '�'� Date --Zr�-!
dy-�r�.��'n, Zlc zi�??i
t�auge # �/4l�''�0�—
llate last accuracy tested /- C S-��
White- Customer's Copy Yellow - City Copy Pink -Tester's Copy