2015-0528 C�IBCK �NE:
IRRIGATION DOMESTIC FIRELINE
BACT�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
N�ME OF Pws: CITY OF COPPELL
�% 1/ (1 L
PWS I.D. # � (�.� I���7 >'�' � SG
LOCATION OF SERVICE: 7 G� N (� L►�� �o� (�,� '
Tbe bacl�low preveation asscmbly detailed below has beea tested aad maintained as required b�, 'I'NRCC
regulazions aad is cerdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuimm Breaker
'� Doublc Check Valvc o Atmosphere Vacuum Breaker
�� �
Manufact�er `�2,�DGO Siu �Z
Model Ivumber �S G Located At ����� (''���� � t��H a S ��('t
�?,��gC� �h �j�ShcS
Serial N�ber -
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst erk 2ad Checl: Reiief�alve Air Inlet Check Valve
Inival Test -Closed 1 � Closed Ti;ht� Opeaed at Opeaed at osid
� Ti ❑ Leal:ed o osid _nsid
R.P-_psid
� Leal:ed ❑ 1 J 1 Did aot Open O Leal:ed o
�P�
and
Mataials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair TighL ❑ nsid _�vsid
RP sid
T'he above is cerdfiod to be true.
Firm Name �� 1 Ls� Certifiod Testa � �" '���'1� �(���'�--�'
Firm Address� �6 S '`G �, `\��1��Cert Testc No.��d 01'61�6 Date �V �� s
(�auge # 0 ��7 GS 6� .
Date last accuracy tested J_�� �
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy