2015_0609 �
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C�iECK ONE:
IRRIGATION_�_ DOMESTIC FIftELINE
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BACKFI.OW PR�VENTIOI�'ASSEMBLY TEST AND MAIIV'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATTON OF SERVICE: � �!J ����r
The bacl�low preveation asscmbly detailed below has bxa tested aad maint�C� as nquired bv T'NRCC
reguladons aad is cercified to be operadng within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressurc Principle e Pressure Vacu�Breaker
;�' Double Chxk VaIve ❑ Atmosphere Vacuum Bnaker
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Maaufacturer �� G�,1 Siu _
Model Number ��� Located At i>� �a����%
Serial N�ber ,f7� ����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Doubie Check Valve Assembly
lst C3eck 2nd Checi: ReIief Valve Air Inlet Check Valve
Initial Test DGClosed Closed Tighc� Opened at Opened at nsid
Tisht �' Leal:ed ❑ osid __osid
RP•�psid
Leal;ed o Did not Opea o L,eal:ed � '
- r ' .; e
'�!�S
�
Materials
. • Used
Test After DC-Closed Clos�d Ti,ht o Opeaed at Opeaod at _�sid
Repair Tight ❑ �Dsid osid
R.P sid
The above is certified to be true.
Firm Name C� lfi� �,�:!�F' �/i,<, �.,., Catified Testa 7�.�-+
Firm Address �� � � �� Cat Tester No. ��vvG��1;Y- Date `� `- `�
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Gauge # ' U
r
llate last accuracy tested -� �-
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy