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Coppell CC 1B1-LR010917 (4)
CtlECK ONE: IRRIGATION DOME~FIC FIRELINE BACKFLOW pRE~gNTION ASSEMBLY TEST AND MAINi'r~ANCE REPORT NAME OF PW$: PWS I.D. # LOCATION OF SEKVICE: TYPE OF ASSEMBLY V~-um~ B~ Vacuum B~mk~ REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check V~lve Ass~nhly 1~ Check 2nd Check Rellef V~ Air Inlet Check Val~e Ti~t ~. ~' I~' - O psid id / P,.P- psid Leaked 0 Didnot~ o ~ Ti~hl o ps/d psid C~t.T~1~rNo. L/O~/'/ Da~ Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - TestePs Copy