2011_1216_RPZ (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
a
510
Oh / a
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
lr
Size 2-
Located At L°0._CoO
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
Do`u,�ble Check Valve
Manufacturer
l
v " OL �S
Model Number
() 09
Serial Number
,"
o2 q / (P
Air Inlet
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
lr
Size 2-
Located At L°0._CoO
The above is certified to be true.
Firm Name _ /( --O S4— Certified Tester P--�V-4,n Z-0
Firm Address 0 . X ?i