2014_0904_RPZ C�IECK ONE:
IRRIGATION DOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: GI��U � �,Cf ��✓� �aC � Z S�
The bacictlow prevmtion asscmbly decailed below has beea ttstcd and ma�ata�ned as required bv TNRCC
re�ulauons and is cerdfied to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
� Reduccd Pressurc Principlc ❑ Pressure Vacu�Breaker
^_ Double Check Valve ❑ Am�osphere Vacuum Breal:er
Maaufact�er r�� Siu � ,I`�" f�
Modei Numbe� ��� �1(12� � Located At i I�:t��„�'.�0 6►i1
Serial N�ber � `T�" ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valv� :�ir Inlet Check Vaive
Initial Test DC-Closcd G��/ Closed Ti�t j� ed at Opeaod at osid
Ti�ht � Leal:ed o �� osid nsid
R.P-_psid �`� �
I,�;� ❑ Did not Opea o Leal:ed �
�P�
and
Materials
Used
Test Af3,er DC-Closed Closed Tight o Opeaed at Opeaed at nsid
Repair Tight o vsid osid
RP sid
The above is catified to be true.
Firm Name��4I� ��c(L+�(ar,� �r Cadfiod Tester ��2oJ l.Ol��i?.��IN�—
Firm Address�22 �o.Jd�(P� ��- Cert. Testc No.���k3� Date ���—��'
�!-°�� *� `7�Z�
c3suge # f 1�1 c?�U�_
llate last accuracy tested -l
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy