2014_0529 C�IECK ONE:
IR.RIGATION V DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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LOCATION OF SERVICE: �� i ��i�G��
The bacl�low preveation assembly detailed below has bcea tested aad maintain� � nq� bv 'I'NRCC
rcguladons and is certified to be operadng within acceptabla paramcters.
TYPE OF ASSEMBLY
e/ �Reduced Pressure Principlc e Pressur�Vacu�Breaker
Q` Double Check VaIve � Amnosphere Vacuum Breal:er
Maaufactiaer �-�bf,� Siu
/ ��
� ,�
Model Ivumber '�� �J �� Located At 7 � G-I'��
Serial Iv�ber ��ti� �%'C�� � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alv�Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Initial Test DGClosed Closed T;�it' Opened at Opened at osid
TiQht Leal:ed o �sid osid
R.P- Z•� Dsid
� P� �;� � Did not Opea o I,eal:ed �
RePaus
and
Materials
Uscd
J Test ARer DC-Closed Closed Ti,ht o Opeaed at Opeaod at __nsid
Repair Tight ❑ ��sid __osid
RP sid
The above is catified to be tcue.
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Firm Name ��/� � �T l Certifiod Tessta 'f �U f '��
� .�,i��� �f �'.% � l/�/`� ,'
Firm Address �� v����n �i��Cat Te,ster No� Date � �
t�auge #
= Od
Date last accuracy tested � �'� -
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy