2014-0708 C�iECB ONE:
LRRIGATION DOMESTIC FIRELINE� 'V
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REppRT
NA1v�OF PwS: CITY OF COPPELL
PWS I.D.#
LOCATTON OF SERVICE: _S"00 �/-���o/-� /��C W�
The bacl�low prevmtion assembly decailed below has bxa tesied and m��nra�n� � nq�� bv T'I�tRCC
reguladons and is cer[ifi�d to bc operanng wit�in acccptable paramcters.
TYPE OF ASSEMBLY
c Ruiuc�Pressurc Princi�lc e Pressurc Vacu�Breaker
i;� Doublc Chcck VaIve o Atinosphcre Vacuum Breal:er
Manufacturcr //V��S Siu � ,
Modei Number � 7'T � !�G'!�► Locaud At I.t��S� ��'G�� d� b'�q_
��n ��f f
Serial N�mmbcr /O D 5 GI 71/ D o�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Ch�ck 4 alve Assembly
lst Checl: 2ad Checi: ReIief Valve Air Inlet Check Valve
Inival Test DC-Closcd � Closcd Ti;ht o Opened at Opened at esid
Tisht ❑ Lcal:cd nsid osid
o�//��� �'-Psid �
�;� Did not Opea ❑ Leal:ed �
�� ��P IQ�,c ��ola�-c
Maurials �'� �-� F� a c�i.�c1�
Used
Test Ai�s DC-Closcd Closed Tight e' Opmcd at Opcued at nsid
�au Tight � 2 osid osid
,� �tp 3�� S�d
The above is ccrtificd to bc true.
� / , �ar^CI �
Firm Name��l'��y 5'�C�S.�h C �_ Cerafied Tesca �v�n JJ
Firm Address '7�> /l�°�'`�' � • Cert. Tcstc No. 13�Do!.�3s I Date /s /�
Gauge # �[Q / 3� �3 �D
Date last accuracy tested 7 �8��o/�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy