2015-0528 (3) C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE
BACI�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
rratv�OF Pws: CITY OF COPPELL
PWS I.D. #r r`�(�\`Ci� S �"�,�-�' � � �7
LOCATION Ol SERVICE: �G� � ����� ���P �,�
Tbe bacl�low preveation asscmbly detailed below has beea tested aad maintained as required by TNRCC
regulanons and is ctrtified to be operating within acceptable parametreers.
TYPE OF ASSEMBLY
C Reduced Pressvre Principle C Pressure Vacu�mm Breaker
� Double Check Valvc o Amiosphere Vacuum Breaker
rj
Manufac�turer �� Siu
Modei Ivumber �� Located At V�'�"��'y `��L ��`�C�'�,
Scrial N�ber �►� ~ I(��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valv�Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test C-Clos Closed Tight � Opeaed at Opened at �osid
' ❑ Leal:ed ❑ esid _osid
�ti��� RP-�sid 'l,,�p
I,�;� ❑ Did aot Opea o Leal:ed O
�P�
and
Macerials
Used
Test ARer DC-Closed Closod Tight o Opened at Opeaod at �sid
Repair Tight o osid osid
• RP sid
The above is cudfied to be ttve. ,
Firm Na�e J�11 ��5� Cetifiod Testa l ,���� GC r� V �
Firm Address��U 6 S ���"1 a.�• ������ Cat Testa Na ��d Q����� n� �� Z3-1S
Vauge # tl 6 G�asG�
llate last accuracy tested S �Z 0 �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy