2014_1017 C�iECK ONE:
IR.RIGATION_� DOMESTIC FIRELINE
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BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT'
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 4-I 3 �—�► SV� L Q n�
The bacl�low preveation assembly detailed beloa has beea tested aad ma�nta�n� � nq� �y 'INRCC
regularions aad is cerdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principle C Pressurc Vacuum Breaker
� Double Chcck Valve % ` ❑/ Amoosphere Vacuum Breaker
�, ( ( i� i�
Manufact�er ��JG Siu �
Model N�ber �s� Locat�d At �� n� �✓� ���
�
Scrial N�ber ��3 7 �
REDUCED PRESSURE PRINCIPLE ASSEII�LY PRESSURE VACUUM BREAI�R
Doubie Check�alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Va1ve
Iniaal Test DGClosed Closed Tight � Opened at Opened at esid
�v �` Tight � Leal:ed ❑ �sid nsid
�� RP_ �' Sld ��g
�;� o Did not Opea o Leal:ed o
airs
and
Mataials
Usod
Test ARet DC-Closed Closed Tight o Opeaed at Opeaod at _�sid
Repair Tight ❑ nsid nsid
RP sid
The above is certified to be true.
Firm Name � v� Certifiod Testa ��- �""1'1
Firm Address � D b X ��0//� Cert Testa No O�Z 7 ZO D� �� " 7-I
� ov►P.r Iridv�l,�(7so27
c3suge # (�3 d^7� ��Z
llate lsst accuracy tested ��1.5��7
White- Customer's Copy Yellow - City Copy Pink-TesteNs Copy