2015_0904 C�IECK ONE: , ,
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY T'EST AND MAINTENANCE REPORT
NAN�OF PwS: CITY OF COPPELL
PWS i.D. #
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LOCATION OF SERVICE: `�`�� � �� �
The bacl.�tlow preveation assembly detaile� below has beea t�sud and maiatained as required bv TNRCC
regulacions and is cerdfied to be operating within acceptable parametrrs.
TYPE OF ASSEMBLY
�C uced Pressvrc Principle � Pressure Vacu�mm Breaker
ble Check Valve ❑ Atmosphere Vacuum Brea�er
Maaufacaaer � -ru Siu >�`'
Model Number L��U Locat�d At i.«� °' ��,{
Scrial N�ber ���j a'`���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CULJM BREAKER
Doubie Check Valve Assembly
ist Check 2nd ecl: ef Valve Air Inlet Check Valve
Iniaal Test DC-Closed losed Ti,Pht Opeaed at Opened at nsid
Tight Leal:ed o _�sid _,osid
RP-_psid
Leal;ed o Did aot Opea o Leal:ed �
�P�
and
Materials
Used
Test Afttt DC-Closed Closed Tight o ppeaed at Opea�at _,,,nsid
Repair TighL o osid __osid
RP sid
The above is certified to be true.
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Firm Name �,'����,;!`�' Catified Testa
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Firm Address & r��,' `�k �'�z��"`=a Cert. Taster Na `f ' `l Date -' - f 5
,� �T � �;,,�,,,
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(igtlge # �� � ;.-t'/,";
Date last accuracy tested `J-a,- ';
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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