2014-1216 C�IECK ONE:
IR.RIGATION DOMESTIC V FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
x�ME OF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � F � � ��`t°�,P D�
'Ibe bacl�low preveation asscmbly detailed below has beea tested aad maintained as required by TNRCC
rcgulanons and is cemfied to bc operating withia acceptable parameters.
TYPE OF ASSEMBLY
c/ Rcduced Pressvrc Principlc e Pressurc Vacui�Breaker
'St� Doublc Chxk Valvc � Atmosphere Vacuum Breal:er
Maaufact�er �� � ��n!S Sizc �rr
Model Number Q-�l'�' Locatcd Az �S�e..f' �Ol�7.
Scrial Nimiber 4 D � � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Checic V alve Assembly
lst Check 2nd Chec3: ReIief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti�[� Opened at Opened at nsid
Tieht *�'� Leal:ed ❑ nsid nsid
���� R.P-_psid
L,�;� p Did not Opea o L,eal:ed �
�P�
and
Materials
Used
Test ARet DGClosed Closed Ti,Qht o Opmed at Opmed at �sid
Repair Tight ❑ �sid osid
RP sid
The above is certifiod to be tive.
� M.�.c.�Jc�s
Firm Name EJ�� F�re.-�+�G-��-�4 Certified Testa � �y71'jw
Firm Address�� 1 �c��•,� P�C� Cert. Teste No "� Date �°��
Gauge # L�L'�� l�� �
llate last accuracy tested �o� '��''j�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy