2017_0309 C�iBCK ONE:
IRRIGATION DOMESTIC � FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 75���,�- Ad1,U'� �
The bacl�low prevmtion asscmbly detailed below has beea tested aad maintained as required bv TNRCC
regulauons aad is catified to be operating withia acccptablc paramcters.
TYPE OF ASSEMBLY
� Reduced Pressurc Principle C Pmsure Vacuimm Breaker
� Double Check Valve ❑ Amiosphere Vacuum Breaker
Manufact�er �11 G. Siu _ L �2��
Model N�ber L�DD�t �;�.f�.`r Located At S� 3�r�n. o� �el��,�u�I,�- 1�1 e� 1�Ia�11tJ1 �owt�,i�
Serial N�ber (�l'� [�S Cn'aL
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Ass�bly
lst Check 2nd Checl: Relief Valve Air Inlet Check Vaive
Inical Test DC-Closed Closed Ti,pht Opened at Opeaed at _nsid
Tight Leal:ed o ��sid _�osid
3`�,\�� R.P-�sid
Lealced � Did not Opea o I,eal;ed o
�P�
and
Materials
Used
Test Aftet DC-Closed Closed?ight o ppened at pp��� Drid
Repair Tight o _�esid _nsid -�
RP sid
The above is cerrified to be tinie.
Fiim Na�e 1,«t -I Qs� Cerafied Tester e�� t�A.w�o,�
Firm Addtess �olleSD St�e TbP1�Er � Cert. Tester No. � `�1°l� Date �F1
i�.11c,s ,� 7sa K3
Gauge # _111�053�
llate last accuracy tested ( Z
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy