2016_1129 C�iECK ONE:
IRItIGATION_�� DOMESTIC FIRELINE
BACT�'I�OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: _ � 1 �'� � �%� 't '
The bacl�low preveation asscmbly detailed below has beea tested and maintained as required by TNRCC
regulations aad is cerdfied to be operating within acctptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuimm Brealcer
� Double Check Valve 0 Atmosphere Vacuum Breal:er
� � 3�
M���a ���Ld _ s� �
Model Number �'� � Locat�d At ",�� �{i� �-f J��� -.. f��(/b.
s��N�� �/� ��1�:�i
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check �ad Checl: ReIief Valve Air Inlet Check Valve
Inival Test DGClosed � Closed Tight � Opened at Opeaed at nsid
Tight f�`� Lealced o nsid osid
RP-._._psid
Leal;od D �- � Did not Opea O Leai►ed O
�P�
aad
Mataials
Used
Test After DC-Closed Closed Tight o Opeaed at Opeaod at �sid
Repair Tight o flsid _osid
RP sid
1'he above is catifiod to be true.
Firm Name � � ' ' �G�v Certifiod Testa r�l�C� l�t���'-t' ��=�-r`��
Firm Address ' Cert. Teste No. � � ' � Date��Cl
�5C� �' 7SG7�-
Gauge # j�f�
llate last accuracy tested � `� �� �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy