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2014_0715 (2) C�iECK ONE: � � r � IR.RIGATION �i DOMESTIC t FIRELINE BACI{�'LOW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAI�OF PWS: CITY OF COPPELL � PWS I.D. # - ` �� 1 I - '�5C1� LOCATIONOFSERVICE: _J` �`�' --l',.� � � I�� I �. �. ��I�P 1 1� I The bacl�low prevmtion asscmbly detailed below has baa ttsitd aad ma�nta�n� � nq�� , '�CC regulations aad is cerdfied to be operating within acccptable paramctcrs. TYPE OF ASSEMBLY C Reduced Pressvrc Principle ❑ Pressure Vacu�Breakcr �'� Double Check Valve o Atmosphere Vacuum Breaker Maaufact�er�:��_�`J � �� I �'�� 7 Siu �,��--�-..�_�� , � ,,_ Model Number � � v Located At t�, �J 1 r'.,�� , � �,�'�k. jl�7-- � �C..��'��? Scrial Nimmber � '� ,� �9 �.G f f`� ��`�. � {� Y^ �•. � REDUCED PRESSURE PRINCIPLE ASSEMBLY 5URE VACUUM BREAKER Doubk Check Valve Assembly '" �>�, . . __ � :_ _ , � lst Check 2nd Checi: Relief Valve �Ajir et` Clucic Valve Inidal Test DGCI sed,/� -Closed Ti;ht Opened at at nsid Tight �.��i Lcal:ed o �sid ��sid ' - � `' R.P-_psid � � -: � ' `' ��' ''4 �� a o ' n�a niat op� o r.�:�a � �� _ 1�� :�-��-� Materials �`v �,% '�`�,; �- �-,� �j. \i t�. �" Used Test After DC-Closed Closed Tight o ppeaed at Opeaed at _nsid Repair Tight ❑ �sid nsid R.P sid The above is certified to be tive. ,, l, � Firm Name 1��' " ^'-�"'�` � � �_ � �� Certified Testc �:��`I�� + ( `!L"�f�'��`�� tk�: . L IL�+`�iG'►� � �� Firm Address�r' I t'��:�-��(�!�I'� Cert. Taster No��6�i�i,(;�r!4 Date j� (�auge #��'t�= C;��-LV i Date Isst accuracy tested �` � ��-> R I y��` White - Customer's Copy Yellow - City Copy Pink-Tester's Copy