2017_0202 C�IECK ONE: .
II�RIGATION ``" "�� DOMESTIC FIRELINE
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BACI�Z.OW PREVEN'TION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PwS: CITY bF COPPELL
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PWS I.D.#
LOCATION OF SERVICE: �'� ,�l. ` . ,; _ :
The bacldlow prevmtion asscmbly detailed below has baa tested aad maintained as requircd bv TNRCC
regularions and is cardfied to bc operating withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principle C Pressure Vacut�Breaker
�� Double Chxk Valve � Atmosphere Vacuum Breal:er
�- , � �
Manufact�ez r-; ; Siu
Model Number Locaud At f.-.. :�`t- J
Serial Ni�ber 1 � -
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�C[J�JM BREAI�R
Doub(e Check Valve Assembly
ist Check 2nd Checl: Relief Valve :1ir Inlet Checic Valve
Initial Test DGClosed Closed Ti�ht °¢� Opened at Opened at osid
Tisht `o Leal:ed o _�sid osid
< RP- ;' - �= Dsid , .,
;, �:> I,�;� ❑ Did not Opea o Leal:ed �
�P�
and
Mataials
Used
Test After DC-Closed Closed Tight o Opened at Opmed at _osid
Repair Tight ❑ �sid vsid
RP sid
The above is certifiod to be tcue.
Firm Name } t " �r Catifiod Tester . �` ;
Firm Address � , , ` Cat Tester No. ``' ; , Date,�y, :
Gauge # i; � ;�. ��1
Date last accuracy tested � � i �:.�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy