2015_0508 (3) C�IECK ONE:
IRRIGATION DOMESTIC �' FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT ,
NAIv�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��r�, `75� C�����,r� �� ��rr�j � `7��1`��
The bacl�low preveation asscmbly detailed below has beea tested aad maintain� � nq� bv Z'NRCC
reeulations aad is certified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle � Pr�essure Vacui�Breaker
�•'" Doubl�Check VaIve o Amzosphere Vacuum Breaker
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Manufactsaer ��-��� Size
Model Number
�.~'^� � � Locaud At ��-`���, �-1'`�d V�'_ ►'t��.{y' �J ,� ✓i��-�c�
Serial N�ber �� � � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R �
Double Check v alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Initial Test DGClosed Closed Ti,Pht Opened at Opened at osid
Ti� Leal:ed o nsid _osid
y R.P-�psid '
�," � 1�- ! j,�;� o i �� D id not Opea O L e a l:e d O
RePairs
aad
Materials
Usod
Test ARer DC-Closed Closed Tight o Opeaed at Opeaod at __nsid
Repair Tight o esid _,flsid
RP sid
The above is certifiad to be true.
� � , j t �
Firm Name �C�i� �'Y1t�C r1U t1 i ��� _ Catifi�d Tester W �`� ' `� �`�` ��-� ist S �' v�
Firm Addres.s � � ��x� � ` Cat Teste No. � � l��S ate � `I�.� ` ��
G.-r.s�;��. �'�.; t�. `�"k `? 5�,��(
cauge # �� �%���y:�-
llate last accuracy tested ��' �S ` ��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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