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2015_1929 I C�IECK ONE: IR.RIGATION �, DOMESTIC FIRELINE BACI�I.OW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT N�ME oF Pws: CITY OF COPPELL PWS I.D. # � ��.� � LOCATION OF SERVICE: _ � � C,� � �/ t ��',`��.� � �- The bacl�low preveation assembly detailed below has beea tested aad maintain� � nq� �v 'I'NRCC regulanons and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle e Pressure Vacu�Brealcer � Double Check Valve o Amiosphere Vacuum Brea�er �r 1 Maaufactiaer �f� F� ��'-� Siu � �..��� r� � s: ; ,� � � Modei Ivumber �- Q � Located At �"�����:.✓ t` B"fc�Y�a t' � _-<_� � , ., , � � , , ;, � �, Serial N�ber �J 4� 1��� �-�'�° ��"<=.�� � �.����" �, , �.. � _ � , REDUCED PRESSURE PRINC�PLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Cbeck Valv�Assembly lst Check 2nd Checi: Relief Valve Air Inlet C'becic Valve Inival Test DC-Closed `Closed Tight Opeaed at Opeaed at nsid Tight Leal:ed o �Dsid _osid R.P-_psid �;� ❑ '� Did not Opea o I,eal:ed o �P� aad Materials Used Test After DC-Closed Closed Tight o Opeaed at Opeaed at _T sid Repair Tight o �sid osid RP sid The above is certifiod to be true. �. - , ; �� --- - _ _. ., � . . Fum Name !�t-zr�._� �H�:� � ��d—r x:- Cecctfiod Testc t'� c''3t�'�-� ,�J' !�:�/Jr�v,r=F�'_.�a C�. . Firm Address "J�"��� �'=�[`:�,F j +=� 7���-�``� Cert. Testv No. �`s��'t'�'if`�_`�:t':'�Date ��._ f��`� Gauge # �)�f ��.�'i�f•� �'=j llate last accuracy tested � ~_�1.-�--r�-� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy