2015_0517 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI4'LOW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT
N�ME oF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: O �� �(� �-�f� '�(— C N
The bacl�low preveation asscmbly detailed below has beea tested aad maintaiaed as nQuired �, TNRCC
reguladons aad is cectified to be operating within acceptable paramtters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacu�Breaker
� Double Check VaIve o Atmosphere Vacuum Bnaker
Manufactsaer ��� Siu �`L�/
Model Ivumber 4 � Located At ��(/rT %�'�
,
Serial Nimiber � � D y e 1�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double C3eck Valv�Assembly
lst Check 2nd Checl: Relief�alve Air Inlet Check Valve
Initial Test DGClosed Closed Tight Opened at Opened at _nsid
Ti�t 8 Leal:ed o �nsid _�nsid
RP- �. psid Z�
Leal:ed o Did not Opea o I,eal;ed o
�PairC
and
Materials
Usod
Test After DC-Closed Closed Tight o Opened at pp��� fl�d
Repair Tight � __nsid _nsid —�
RP sid
The 3bove iS cettifig�rf�Aab�e��on
3901 Cl on br. �� ����'�/�
Firm Name Richardson, Tz. 75082 CCRifiod TCStC
n ara a on
3901 Cl�on Dr.
Firm Addc+ess Richardson. Tx. 75082 Cat Testar No. �3� � Date �1�"�,S
(3auge � `fd�C/�!�l� � >(� �a ��
llate last accuracy tested l(— Zc�—r y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy