LoanMeter C�IECK ONE: ��'� �,OG�y�q ��"�'� r'
IRRIGATION DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAIN'I'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: g +� S e� D�t I I /Z�:
The bacl�low preveation asscmbly detailed below has bcea tested aad maint�in� � nq�� � '�CC
regulations and is ceraified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle � Pressurc Vacu�Breaker
�� Double Check Valve o Amaosphere Vacuum Breal:er
J r�
Maaufactsaer �l T�S Siu �
Model Number �0 �� � � � Located At
Scrial Nimmbcr o l l � 9 �--
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 'nd Chec1: Relief Valve Air Inlet Check Valve
Inidal Test DGClosed Closed Ti,Qht Opened at Opened at nsid
��, Tight Z r� � Leal:ed o nsid _osid
�i� J� �--j�s�a g
� I,eat;ed ❑ Z` Did not Opea � Leal:ed o
�P�
and
Materials
Usod
Test ARer DC-Closed Closed Tight o Opened at Opeaod at �sid
Repair Tight ❑ �sid _osid
RP sid
The above is catifiod to be true.
�J� r r� ��J �c.0 i S
Firm Name Certifiod Testa � �1
Firm Address Cert. TGster No. g P�0 0 1�7�D�
cg� � ��b 2 3 �f? 3
llate last accuracy tested �P � l`f
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy