2014_1007 CHECK ONE:
IR.RIGATION DOMESTIC FIRELINE X
BACIQ�'LOW PREVENTiON ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: Estates of Coppell 1007 Independence
The baci�low prevtntion assembly detailod be3ow has been tested aad maintainpd � nq� �v �CC
regulario�s and is czrtified to be operating withia acuptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressvre Priaciple e Pressure Vacuimm Breaker
�3 Double Check Valve ❑ Amiosphtre Vacuum Breaker
Maaufact�er Qarn�_S Siu � �•
�i N�bQ o�o013 �ua Ac l�'71 l r�leaPrd�.c� —Gia�
Serial Nimmbcr ����as
REDUCED PRESSURE PRINCII'LE ASSEMBLY PRESSURE VAC[TUM BREAI�R '
Double Check�alve Ass�bly '
lst Check 2nd Cbecl: Rdief Valve Air ldet Check Va1ve '
Inidal Test DC-Closcd Closed Tight Openod at Opene�at _osid
Tight � ,�3 Leal:ed � � � ❑ nsid _nsid
RP-__psid I
Leal:ed ❑ Did not Open ❑ Leal:ed 0 ',
RePairs 1
aad �� � i
Materiats
" Usod :
Test After DGClosed Closed Tight o Opened at Opmod at nsid
_�
Repair Tight a Dsid �sid j
RP id
The above is certi6od to be true. �
F1talNa�e1-AFire&Domestic Tes'ting CCtCt$C�T� I
Fj��PO BOx 79548 Cpt Z'�g�j�JO.BPooi53s5 � Datc f`� � r �
Fort Worth Tx 76179
Gauge # 06070576
Date last accuracy tested 12/3/13
White-Customer's Copy Yellow -City Copy Pink-TesteNs Copy