2016_0530 C�iECK ONE:
ItIGATIO ,� _ DOMESTIC FIRELINE
BACI�7.OW PREVENTION ASSEMBLY TEST AND NtAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: �a0 � -P�.�t�r�b�' '�i � '
The bacl�low preveation asscmbly detailed below has baa testcd and maiatained as requir�d by 'I'NRCC
reQulations aad is cerrified to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressurc Vacuum Breaktr
,� Doublc Chxk Vaive o Amiosphere Vacuum Breal:er
Maaufactiaer �.��. - S� Zw •
Model Number��•� � p' Located At �e►7�'���'��`�'c�.A1___��r,�"
Scriat N�ber �� 1 "7.N1
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Va1ve Assembly
1�(y� 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DGClosed � f�( Closod?ight �l Opened at Opened at esid
Tight � Leal:ed o esid _nsid
�-�6 �-_Ps�a
�� � I ,1p Dia noc Opea o Leal►ed �
�P�
and
Materials
Used
Test Aftet DC-Closed Closed Tight o Opened at Opmod at �sid
Repair Tighi ❑ Dsid ___,osid
Rp sid
The above is certifi�to be true.
Firm Name�—�''''T� Catified Testa��L l/�fs,��r'O vJ�n
Firm Address I�� J Cert. Tester No.B i �C�b Date �
Gauge # � 'C� �. �,Z,2
llate last accuracy tested ���� _
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy