2016_0301 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINB
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAI�OF PwS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: �GSl7i�P I� 11P//^ �' y�� ��� ��I
The bacl�low prevmtion assembly detailed below has beea tested aad ma�nta�n� � nq�� bv TNRCC
regulaaons and is cerrofied to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressur�Vacu�Breaker
� Doublc Check Valve o Amzosphere Vacuum Breaker
Maaufacuaer (.LfL� S Siu ���'
Modei Iv�mmber
L�Q�7lh��l� Located At ����l�
Serial N�ber ���.3 ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Checic Valve Assembly
lst Check 2nd Checl: ReIief Valve Air Inlet Checic Va1ve
Inival Test DGClosed ��O Closed Tight Opcned at Opened at �id
Ti�t d Leal:ed ❑ osid �sid
R.P-_psid
� _ ' ' �;� � Z� Did not Open � Leal:ed J
�P�
aad
� Mataials
Used
Test AR,er DC-Closed Closed Tight o Opeaed at Opmed at __�sid
Repair Tight 0 �sid ___..,Dsid
R.P sid
O '
The above is catified w be true.
Firm Name � �' 1'� � ��� CertiS�ed Testa ���iA�'1 I��11���il�i Y!'1
� �. � Date ���"��
g�p� Cert. Testc No.
����� ��
Gauge #
llate last accuracy tested _ ����'��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy