2015_0427 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��� C�"�`''��✓�--
'Ibe bacl�low prevtntion assembly detailed below has beea tested aad ma�ntain� � nq�� �, �CC
reguladons and is certified to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
e ,�Reduced Pressure Principle ❑ Pressure Vacutmm Brealcer
�� Double Check Valvc o Atmosphere Vacuum Breaker
Manufact�er ��'�� S;ze �,�,'`
Model N�ber �=o Located At 1�.�,.,� `��.-/
Scrial N�ber �sc�7��r
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Chec�: 'ef Valve Air Inlet Check Valve
Inidal Test DGClosed ` losed Ti,Pht Opeaed at Opened at _osid �
Ti�t �. � Leal:ed ❑ nsid _osid
R.P-_psid � ., r
Leal;ed ❑ Did noc Opea o L,ea1;e� K � ,
RePairs
aad '
Mat�rials '
Used
Test Ai�ex DGClosed Closed Tight o ppened at Opeaed at �sid '
Repair Tight o nsid nsid
RP sid
The above is catified to be true.
Firm Name I'�� v��1 C./e Catified Testa �!�
Firm Address ��' �°" ���� Cert Testc No. ,8���.Y��`/ZDate 7_ ��r-i�l
/�/,.�,./�,. ��
J
Gauge # /�t��SdS
llate last accuracy tested ��� 2 7 � /�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy