2015_1016 C�IECK ONE:
IR.RIGATION � DOMESTIC FIRELINE
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L:%' � ��-`�` O-',_� �•/'`--I� ��,1 �j
,
The bacl�low prevmtion asscmbly detailed below has beea tesLed $ad ma�ntain� � nq� bv T'NRCC
re_¢ulazions aad is certified to be operating within acceptablc paramtters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressure Vacu�Breaker
� Double Check Valve ❑ Amiospherc Vacuum Breaker
Maaufacaaer 1.�,�a l., �;i a„ `> Siu �l
Model Number ,_.:� ��U Located At �� '�'�-����'� `/�1 d?�;'
Serial N�ber /� ..�� �7 �'M�l i
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Y
Double Check Valve Assembly
� lst Check 2nd Checl: Relief Valve Air Inlet ;Check Valve
Inival Test DGClosed Closed Tight t�- �Opeaed at Opened at osid
Tight ,2, -� Leal:ed ❑ nsid �usid
R.P-_psid �� `�
�;� p Did aot Opea O Leal:e� o
RePairs
and
Mataials
Used
Test ARet DC-Closed Closed Ti,pht o Opened at Opeae�at �sid
Repair Tight 0 �sid osid
RP sid
The above is certified to be true.
('"� � �'l '•� • .�'�r {' 1-f.-7(. C �;i{_/•J' � �-
Firm Name -� i "' --� l`' CQt1fiOd TCS� r
�;G•ia� �`�""! = �11� �:O _, .—��,
Firm Address ��a�'�!`��� �.�" Cat Taster No. �� �� `�>r'=� Date�t=; �'� �. ,'`� ' >
Gauge # �;••`f;�';:-�'�-i 1 (,,• �l -�
Date last accuracy tested `�;� ( r �� )�r
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy