2015_0212 (3) C�IECK QNE:.
LRRIGATION DOMESTIC �� FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: N+ i"!k:_� ��+ �t?e�'111 v►''i 1.��y"�i1`� � I r ��.%�-,�/ `-�r
The bacl�low prevmtion assembly detailod below has beea tested aad ma�ntain� � nq� �, '�CC
regulauons aad is cerafied to be operating within acceptablc paramctcrs.
TYPE OF ASSEMBLY
�''` Reduced Pressure Principle � Pmsure Vacu�Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Maaufactsaer W����5 Siu
1 ''
Modei Number C�C7�'I V�'1 ,-� �..�� Located At .��d ����=r� � 1 i�,jC i�� rr�a_c��;..�� •, r a" ��,,;,.�-:
s��N,�ba ��� �-71
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check v alve Assembly
lst C3eck 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Tight ed at Opeaed at osid
Tight Lcal:ed o �sid _osid
� ��_ �� R.P- �► � sid `�
� �� p 7, d Did not Opea o Leal:ed o
RePairs
aad
Materials
Usod
Test ARer DC-Closed Closed Tight o pp��at Opeaod at �sid
Repair Tight o osid __osid
R.P sid
The above is catifiod to be true.
Firm Name �n�K Yr�[G�.'z r'1� °��c � Certified Testa W �� I( �,:ti,rr�� ���V��ti. t%,
Firm Address '���'���,�f�-= Cat Tester No. o�I f S ����
�r
��'S �c,�?�1 ��� � � (�v`; `1'� `7,jt`�/
Gauge � C4_�ll c�:�`1�
._7
llate last accuracy tested � �"" � '` � �
White - Customer's Copy Yellow - City Copy Pink -Tester's Copy
i _