2015_0820 C�iECK ONE:
IRRIGATION_� DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
�
LOCATIOIv'OF SERVICE: '
The bacl�low prevmtion assembly detailed below has beea tested aad ma�ntain� � nq� bv I'NRCC
reguladons aad is cetified to be operating wit6in acceptablc paramtters.
TYPE OF ASSEMBLY
e Reduced Pressurc Principle � Pressure Vacui�Breaker
� Double Check Valve o Atmosphere Vacuum Breal:er
Maaufact�aer 1-J��l�i�,-�S Siu 3�L� i�
Model N�ber 35 C� Located At �C G�G S� t-�D rrl Y�._e,t e�
Scrial Nimmber f� S�� ����
��--1�'—���z
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DGClosed��� Closed Tight � Opened at Opeaed at osid
Tight � Leal:ed o __,,,osid nsid
�_—,ps�a 3.m
�;� p Did not Open � Leal:ed �
�P�
and
Materials
Usod
Test Aft,er DC-Closed Closod Tight a Opeaed at Opmed at __,�sid
Repair Tight o osid ___nsid
R.P sid
The above is cadfied to be true. `
Firm Name ���curscv$acktlow Certified Testa � �
�'9�0 Bsrto� �ir-cle �-��-��
Firm Address • Cert Tater Na � Date
�
(3auge #
. �
llate last accuracy tested � '
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy