2014_0730_RPZ (9) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE V
BACI�'I,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:.S}t. /��., v,� �7/7�`l�e��;'�,-�'��a,,�/�� ���/�
The bacl�low prevmtion asscmbly detailed below has beea tested aad maintained as nquired by INRCC
regulations aad is cerci5ed to be operating within ac�tptable parameters.
TYPE OF ASSEMBLY
F'� Reduced Pressure Principle C Pressure Vacu�mm Breaker
^ Double Chxk Valve ❑ Atmosphere Vacuum Breaket
Maaufacuaer
�/� f�� s� 2 ��
Model N�ber �-'-�C'I�ZQ T Located At �'!'S� �' r''��r��� �`/�
J
SCI131 T11mm�Q �� 7 ��.��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Reiief Valve Air Inlet Check Valve
Inival Test DC-Closed Closed Tight !z' ed at Opened at esid
Ti,�t Leal:ed o C�psid _osid
R.P-�sid �/ / �
L,eal:cd o Did not Opea O Leal;ed �
RePair�
and
Mataials
Usod
Test Aftet DC-Closed Closed Tight o pp�ned at ppeaod at _�sid
Repair Tight o _csid osid
R.P sid
The above is cadfied to be�ue.
Firm Name �G'I`Yr� L �M�! -- Certifi�Testc--� � �y`''1 ���Cb'�
Firm Addres.s��g1�lo7G t�l�vri�� � Cert. Testc No���v�'g�G� Date�/�lJ��
7�G'r�'`f
(�auge # ^`���/O �>a
llate last accuracy tested 3
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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