2014_0730_RPZ (11) _ _
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
rr,�,�oF Pws: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE:S�. /VI�ri h �7�.Z'�1rJl�t�•� ������x � �/�_
The bacl�low prcvmtion asscmbly detailed below has baa tested aad maintained as required by TNRCC
regulanons and is cerdfied to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle � Pmsure Vacu�mm Breaker
� Double Check Valve ❑ Atmosphere Vacuum Breaker
�f
Maaufacnaer l.�r li"fS Siu �
Model N�ber �!�3 -�f'/�'I�. �T Locatod At �''� �c'' r r�v� ,����1�
Serial Nimmber /�.1 �9�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Reiief Valve Air Inlet Checic Valve
Inidal Test DGClosed Closed Ti;ht g Opened at Opened at osid
Ti�ht - „ Leal:ed o ` �� sid __nsid
RP�.�sid S,�
Leal;cd o Did not Opea � Leal:ed �
�P�
and
Materials
Used
Test After DGClosed Closed Tight O Opeaed at Opeaed at _nsid
Repair Tight o _csid osid
RP sid
T'he above is cadfied to be tnu.
Firm Name�L'0"Y�s �oh-�r�-i Cctifiod Tesca J e r rc, ,S�C�U K
Fum Address�'d dl l. �C�t r%i✓.x�r�r i�_`l,`��, Cert. Testet No��'/,��5�'�lo�i' Date 7��e//e/
?���/
ca� � �f�D�0�S�
Date last accuracy tested .3 L
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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