2011_1128 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 955 t/' e C ` <: X �-
The back2ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
Manufacturer Hex S Y
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size _--
Located At // ry • G'l),_ % I-
The above is certified to be true.
Firm Name l)d) c _/4'r
Firm Address P l%, l3, / 7 17 1U,4 /,Vz
Gauge # O t, c 11 1 1 `! i