2015_0629 (2) ��
C�IECK ONE:
LRRIGATION DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAN�OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: I D 7� 5 ` b�.I�- ] �'.�,� 1� .
The bacl�low prevmtion asscmbly detailed below has beea tasted and maintain� � nq� bv T'NRCC
regulations aad is cerdfied to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
1�' Reduced Pressure Priaciple e Pressure Vacu�Breaker
^_ Doublc Check Valvc o Amzosphere Vacuum Breaker
Maaufactiaer i•�1 u��-5 Siu �- 5-- ��
Modei Number 0� �r� �T Locaud At ��K �1 U►1�
s«��N�ba Aa3���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check v alve Ass�bly
lst Check 2nd Checl: Relief Vatve Air ldet Checic Valve
Iniaal Test DC-Closed Closed?ight I� ed at Opened at esid
Tight � Leal:ed ❑ � sid _nsid
/,Z�//� RP-�sid �.t�
Leal;ed o Did not Opea o I,eal:ed �
�P�
and
Materials
Used
Test Aft,et DC-Closed Closed Tight o ppeaed at Opeaed at _�sid
Repair Tight o flsid osid
R.P sid
The above is catifiod to be true.
FirmName �v.v�� �o�rri.r�,'�,� CatifiiedTeste I�o�r-�" �.�'��
ISoo 5.�e����.� ��'e�""`•y ''`�� � oG�y3`�El Date
Firm Address c,wN�� T� Cert Tester No. �
c�auge # C�3 I aZ 3 O 3�
Date last accuracy tested �� - �3`�S
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
I �