2015_1022 C�iECK ONE:
IRRIGATION �.r'', DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� �� f�<� ,� ��r'--���� <�
The bacl�]ow preveation assembly detailed below has beea tested and maintain� � nq�� bv TI�IRCC
regulauons aad is certified to be operating within acceptable paramtters.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciple C Pressure Vacu�Breaker
� Double Check Valve ❑ Amnosphere Vacuum Breal:er
Maaufactiaer �~�-//'� C? Siu ./ `-/
.. �._..
Model Number ,_� '-�>�.-'� Located At % ,��,-�;` i ��`' �t i,j`
Serial N�ber �`��° l`�% �r ���'
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly �
lst C3eck 2nd Checl: Relief Valve Air Inlet Checic Valve
Inidal Test DC-Closed Closod Ti,,P.ht er Opened at Opened at �flsid ;
Ti�i�i�} -dr Leal:ed o esid osid °
R.P-_psid �, <:-�
I,�;� ❑ ` Did not Opea ❑ Leal:ed o
�P�
and
Mataials
Used
Test After DGClosed Closed Tight o ppeaed at Opeaed at __�sid
Repair Ti�t ❑ osid osid
RP sid
The above is cetified to be tnu.
,1�
Firm Name `-� _� �J' Catifiod Testa % '`'� t`�`d��:; t �-`'` �` `
. -� r
�,��,�� � ;� �� � ��� � �_.
Fitm Address `%�`:";r ,�`,�= ����-' Cert. Testet No. ? �`� ` '�'i Date r°�'1,��� a�
Gauge � � '� ���4 i�.-���� ��1 �
llate last accuracy tested i f � ,f� t
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy