2014_0909_RPZ C�IECK ONE:
IR.RIG /
ATION DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORZ'
NAN�OF PWS: CITY OF COPPELL
PWS I.D.# I av► ; �w or
LOCATION OF SERVICE: ��
The bacl�low prevtntion asscmbly detailed below has been tested aad maintained as required by TNRCC
regulations aad is cerdfied to be operating within acceptable parame�ters.
/ TYPE OF ASSEMBLY
�� Rcduced Pressvre Priaciplc ❑ Pressure Vacu�Breaktr
� Doublc Check Valve ❑ Amaosphere Vacuum Bnaker
Maaufactiaer W� Siu �µ
Modei Ni�ber OD�1.�1�2 Located At ��`W� � �'.105�'1
Scrial Nimmber /'�aqyV�1
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check v alve Assrmbly
lst Check 2nd Checl: 'ef Valve Air Inlet Check Valve
Initial Test DGClosed Closod Tight at Opeaed at nsid
Tight Leal:ed ❑ sid osid
RP-�sid �
��'� Leal:ed ❑ � �� Did not ea � Leaked o
OP
�P�
and
Materials
Usod
Test After DC-Closed Closed Tight o Opeaed at Opeaed at _�sid
Repair Tight o osid esid
RP sid
The above is certified to be true.
Firm Name� �� Catifiod Testa �
Firm � 1�4� � �1� � Cat Testar No. OO 1 �.P Date � � IU
A�� �c �l�a 4
cauge # D�o�o�
Date last accuracy tested
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy