2015_0416 C�IECK ONE: • � ��
IRRIGATION DOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT
rrAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � �� � o �E�'l �Q1r1 ~ � �+°t�'i 1'�C;� . s j-C�-�„�,C�
The bacictlow preveation asscmbly detailod below has beea tesud aad mainrain� � nq�� �, �CC
rcguladons and is certified to be operating withia acceptable parameters.
� TYPE OF ASSEMBLY
Reduced Pressvre Principle ❑ Pressur�Vacuimm Breaker
D Double C�eck Valve o Atmosphere Vacuum Bnaker
` � � �� R�
Maaufactiaer W ��'`�"� Siu
Model N�ber LF oo� r1�Q�` Located At ` � - Q7�1 � �y��%
T- �����'-`'�'
serial Nimmber C�� i �,1�^7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check Valve Assembly
lst Check �nd Checl: Relief Valve Air Inlet Check Valve
Iainal Test DGClosed �Closed Ti,Pht Opened at Opened at osid
Ti,i�t Leal:ed o � o sid _�nsid
RP- 9.`� nsid
Leal:ed o Did not Opea o Leal:ed J
RePair� �
aad
Materials
Used
Test After DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair Tighi ❑ �sid �sid
R.P sid
The above is certified to be true.
Firm Name�'`-�v��:�fHc� bc-�,,,(�^ri a'�'� Certifiod Teste .���'�C`'i"> f'i r S J��j�
f
Firm Address �` Cert. Testar No.' � Date�_��j
l_�:='��i'�r�r l�X ?F::�`a���,
(3auge # .��`'�s!�'.)1 l�, ��`��
llate last accuracy tested � � -/ �=y
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
� _