2014-0317 (4) C�iECK ONE:
IRRIGATION DOMESTIC FIRELINE �
BACI�ZOW PREVENTION ASSEMBLY TEST AND MAIN'I'ENANCE REPORT
N.4I�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � �� C���'��'�'� �
The bacl�low prevmtion asscmbly detailed below has bxa tested and maint ;n� � nq�� �, '�CC
regulanons and is cerdfied to be operating within ac,ceptable parameteers.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressure Vacuimm Breaker
� Doubla Chcck Valve o Atmosphcre Vacuum Breaker
�
Maaufact�er ��� ��1 Siu y
Model Number �� � ��`� Located At 5_GC_ �����l�
Serial N�ber �� % �G �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Initial Test DC-Close� Closed Ti;ht �f Opeaed at Opened at _nsid
Ti�t f-y '� Leal:ed l,w o Dsld �Sid
xP-_ps�a
Leai;ed a Dia noc Opea o L,eal:ed a
�P�
and
Materials
Used
Test After DC-Closed Closed Tight o Opened at Opeaed at �sid
Repair Tight � nsid __nsid
R.P sid
The above is cerrified to be true.
Firm Name �c���i� �����f Catified Testa �������� � ��i���" ��
Firm Address ���-f c X 7�7 l,L r,�X���"x Cert Taster No. �rc�cc T c�- Date //� -��
(�suge # GG�`��� ��
1�ate last accuracy tested 3 "���-�C/
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy