2015_0904 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIIVTENA1riCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: ���� L�,��, -�
� '� � ` �
The bacl�low prevmtion asscmbly detailed below has beea iested aad ma�nta�n� � nq� bv 'I`N�tCC
re_guladons and is cerdfied to be operating wiihia acceptable paramcters. �, � �.�
TYPE OF ASSEMBLY .
e �'' Reduced Pressvre Principle e Pressurc Vacu�Breaker
^.�'' Double Check Valve � Am�osphere Vacuum Breaker
Maaufacuaer 1���,cP Siu �`,'
Modei Number `�'� _ Locatcd At �.�- �` `��' '�
;r,i"t��f,.;,!o
SCI131 T11�1bCr
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUIJM BREAI�R
Double Check v alve Assembly '
lst Check 2nd Checl: 'ef Valve Air Inlet Checic Valve
` Inival Test DGClosed losed Ti�t Opened at Opened at osid
Ti�t ,� �� Leal:ed � �, a nsid _osid
�.c�/_ �`� RP-__Psid
�;� ❑ Did not Opea o Leal;ed o
RePairs '
and
Mataials
Usod
Test After DC-Closed Closod Tight o ppeaed at Opeaed at �sid
Repair Tight ❑ �flsid _^osid
RP sid
The above is cerdfiod to be true. �
f �� /
Firm Name ����;`r'C�� � � Catifiod Testa �� �f
Firm Address�rY X �7'=���> Cert. Testa No. 15i'����"'l Date `�' `'y' ��
� -
�,{/,��+' y
�� r.�/ F. • �" f('�/.�•9i
�igllg@ � �,',^�7;fG;`,
llate last accuracy tested - '`: ��.
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy