2015_0720 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�'i.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �� � � � ��� � � �
The bacl�low preveation assembly decailed below has baa tasted aad fiaintain� � reqnired by INRCC
re_gularions and is cerdfied to be operating wittria acceptable paramcters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle e Pressure Vacu�Brealcer
� Double Check Valvc o Atmosphere Vacuum Breaker
Maaufact�aer ��'�`�--- Siu _ '�`�
Modei Number �� Locaud At ���°'�"��
Scrial Nimmbcr '�'✓ ' r �'� ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly '
1��� �ad Checi: Relief Valve Air Inlet Check Va1ve
Inidal Test DGClosed osed Ti,�ht Opened at Opeaed at nsid
Ti�ht Leal:ed ❑ vsid osid
��sid �
❑ � Did not Opea � Leal:ed �
�P�
aad
Materials
Used
Test ARer DC-Closed Closod Tight ❑ Opened at Opeaed at �s�d
Repair Tight a �sid _csid
Rp sid
The above is catified to be true.
Fum Name
(� 1�112 i� ��� Cetified Testa � L/ ��'�� �'Q Y1
�
Firm Address ��� C-�I �''v' Cat Testc No. � Date `�_��
Gauge � �J�IZ'I�-�� � ( Z- � �
Date last accuracy tested�"�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy