2015_1123 C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINB
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REppRT
NAIv�OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L I� J � �14�� /�
The bacl�low preveation asscmbly detailed beloa has beea testod aad maintain� � nq� �, '�CC
reguladons aad is cerdfied W be operating within acr.eptable paramcters.
TYPE OF ASSEMBLY
C rReduced Pressure Principle � Pressure Vacu�Breaker
��� Double Check Valve o Amaosphere Vacuum Bnaker
Manufactsaer � ��``� Siu ���
Model Nimmber � Locaud At '�" '"��'� 1� /���c.�
Serial N�ber l 1- � � 2 cJ Z� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSiJRE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Checic Valve
Inidal Test DGClosed Closed Ti�ht Opeaed at Opened at �id
Ti�t Leal:ed o nsid _osid
RP-�.psid `�
L,ealced o i Did not Opea ❑ L,eal:ed o
�P�
and
Mataials
Usod
Test After DC-Closed Closed Tight o Opmed at Opeaod at �sid
Repair Tight 0 �sid �sid
RP sid
The above is cerd6od to be true. �
Firm NamelJl�NOR�{� -��, Certified Tester � ��D�`�f�!9
,�, 2�
Firm Addres,s ��'D C � �`�7)'..v Cert. Testc No. ���l S Z Date I/- Z�" l
Gauge # _��� ��-f� �� 2 � � /
llate last accuracy tested `�2�i'�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy