2015_1203 C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAINZ'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��� � ��7� ���5 �
The bacl�low prevmtion assembly detailed below has bem tested and maintain� � nq� �, '�gCC
re_�ons and is certified to be opera�ng withia acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principle C Pressurc Vacu�Breaker
❑ Double Chcck Valve , ❑ Atmosphere Vacuum Breaker
Maaufact�er �� �C� Siu
Model N�ber 4 � Locaud At �� ��
Serial N�ber � � Z��)-�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check Valve Assembly
lst Check 2.nd Checl: Reiief Valve Air Inlet Checic Valve
Inidal Test DGClosed osed Ti,�ht Opeaed at Opeaed at nsid
Ti�i Leal:ed o nsid _�osid
RP-�psid �
Leal:ed o � Did not Open o Lesl:ed o
�P�
and
Mataials
Usod
Test Aft,er DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair Tighi o _�sid osid
R.P sid
The above is catified to be we.
� �K� �����
Fum Na�� I�-� Caafiod Testa ��
Firm Address �� � ��/ ��`J Cert. TGsta No.��(��/SZ- Dace � Z�'—� 5
c8� � ����l� 3�L 6 S�
Date last accuracy tested ,l� �3"��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy