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2015_1123 C�IECK ONE: IRI�IGATION DOMESTIC FIRELINE BACI�'LOW PREVENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REppRT rr�OF Pws: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: �"l � �/T�P'�'��O/� The bacl��flow prevention assembly detailed below has beea tested aad mainj i�npd � nq�� , �CC regulations aad is cetified to be operating within acceptable paramctcrs. TYPE OF ASSEMBLY �C Reduced Pressure Principle e Pressure Vacui�Brealcer Double Check Valve ❑ Amnosphere Vacuum Breaker � Maaufactiaer � �� Siu �, Modei lv�ber � Located At � �--`7� � +�, Serial Nimmber � � �U L� "1�� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Doubie Check Valve Ass�bly lst Check 2nd Checl: Reiief�alve Air Inlet Checic Valve Inidal Test DGClosed Closed Ti,Aht Opeaed at Opeaed at nsid Tight Leal:ed 0 �sid __osid -s �- f� S�a � j ` Leal:ed ❑ Dia noc opea o L,eal:ed � �Pa;,t and Materials Usod Test After DC•Closed Closed Tight a Opeaed at Opea�at _�sid Repair Tighi o �sid �sid RP sid The above is catified to be true. Fiim Name ��iq'�-f� �2�- Cctifiod Testc �Y� L� J'4�UO14�� Firm Address ��( �Q��-� �✓� Cert. Testa No.�� S Date �I''Z 'Y� (�auge � ��(./� �%� �� 2 �° � llate last accuracy tested �r Z � `�� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy