2015_1013 `C�iECK ONE:
IRRIGATION /� DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND �?'"""`��'�-�""-�-�---��- .
.._. NAME OF P�yS ,. .; CITY OF COPPELL , � , , ; p �� �
PWS I.D. #
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LOCATION OF SERVICE: � `' � .%�f`�� �`�'�f�� ��[�
The bacl�low prevmtion asscmbly detailod below has beea t�sted aad mainta�n� � nq� bv '1'NRCC
reguladons aad is cerdfied to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle e Pmsurc Vacu�Breaker
rOi"" Double Check Valve o Atmosphere Vacuum Breaker
Maaufact�uer ��✓� !� �9 v � Siu :��-�'
Modei Iv�ber -'� ��' `-� Located At /N���`�'-�/I s f,.�'r�z ,�'
Scrial N�ber �}�i'`I`� � ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet �Chetk Valve
Inival Test DGClosed Closed Tight Opened at Opened at nsid
Ti�t �� � Leal:ed o nsid nsid
RP-_psid ;;�, �
�;� ❑ Did aot Open O Leal:ed �
��
aad
Mataials
Usod
Test After DGClosed Closed Tight o Openod at Opeaod at �sid
Repair Tight o esid osid
RP sid
The above is cestified to be true.
, ., ; ,,-, • - '` � �
Fum Name a %--=y �i C�•C._.. Certifiod Testa 1/`"i r c.' ,�i��;. � ,�.. v�� .� t_-
G�'�� �� ?r�/�G•�" _
Firm Addc+ess �,�7��`i`;��� �X� Cat Teste Na ��_T�_`..� � Date��'l' '� J' `�>
Gauge # � �r-v''-! !�'� �� `?
Date lsst accuracy tested `,� �r �- " __
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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