2015-0528 (2) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # _ l�fi�-�\`Qi� ��'��'�,-�' � S6`�
LOCATION OF SERVICE: 7G� N ►/ e�� fi``� I\,�
The bacl�low preveation assembly deraile� below has beea tested aad ma�n a�n� � nq� �, �CC
reguladons aad is cerdfied to be operating within acceptablc parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle C Pressurc Vacu�Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
� ��
Maaufactzaer w ���j Siu r�
Modei Number ��� � Located At i!n.��� `��^-� �/l`�'ro•U� L�.
Scrial Nimmber L � �I tl J
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CULJM BREAKER
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Va1ve
Inidal Test Closed Ti,Qht� Opeaed at Opeaed at osid
�p S S Ti d ❑ Leal:ed o �sid _�sid
\� RP- 2_,Dsid v
I,eal;ed ❑ t � D Did not Opea o L,eal:ed �
�P�
and
Mataials
Usod
Test After DC-Closed Closed Tight o Opeaed at Opeaod at _�sid
Repair Tighi o nsid osid
RP sid
The above is catifiod to be true.
Firm Name �l) ��� C«tifiod Testa �-��'�"`����' CO�I'� �-t�'
Firm Add�ess IZo CS �'` (� ����� Cert Testc No. ���6�� Date U����s
Gauge # 0 6��G���
llate last accuracy tested ��Z�� �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy