2014_0910 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE /�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL a
PWS I.D.# �
4
LOCATION OF SERVICE: `� ��"e� .S �„ �=l_ .�%�;:.� �y J (�� . " rp�.r'i' 7
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The bacl�low preveation assembly detailed below has beea testod aad maintain� � nq�� bv 'I'NRCC
regulations and is cerdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Rcduced Pressurc Principle e Pressure Vacu�mm Break�
.
Double Chec�C VaIv4 t...y� o A�o�here Vac�}um Breal:c
_ ._.. _ _ .. �..�.. . .
. _..,, _. . .. ..
Maaufact�er G,�. �k;.��= Siu r�
Model Number �' ��f�" `.� � �' Located Ai J�( �� ��
Serial Nimmber / S 7 .� �'�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAKER
Double Check Valve Assembly 4
;
1st Check ?nd Chec�: Relief Valve Air Inlet Check Valve �
Inival Test DC-Closed Closed Tight � Opened at Opened at _nsid �
Tight � Leal:ed o _�sid osid
RP- a � �sid �
� . �`-;� L,�;� p �" � Did not Open o Leal:ed o
�P�
aad
Mataials
Used ' �- , �
_ , ; , - , - . �:
Test After DC-Closed Closed Tight o Opened at Opeaed at ' __nsid
Repair Tight ❑ nsid osid
R.P sid
The above is certified to be true.
Firm Name ���-./�� f ^_ �''c �c�`� Certifiad Testa {� -'�-�
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� .��.��'������- ��`� ��Cat TasterNo. ��'D/s_�y��"Date / .:� �
Firm Address ,�:�= t�%'
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�� (�suge # �.=�,�a��=� %��. � ,:
llate last accuracy tested ej r � !r/
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy