2014_0730_RPZ (5) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:5'�./1'��r,'rr l7/7��.�3���.�yi c �rr�a��c//� 7Sfi%,-�'�
'Ibe bacictlow prevmtion assembly detailod below has beea tested and maintained as required by TNRCC
regulations aad is cerrified to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle C Pressur�Vacu�Breaktr
� Double Check Valve � Amiosphere Vacuum Br�eaker
,
/ J �t r�
Maaufactiaer /�/�► ��-� Siu ;�
Modei Nimnber /i f������ Locaced At Y1�SL r Y�v in 131���,J
Serial Nt�ber ��L/�a l
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Cherk Valve Assembly
lst Check 2nd Checi: Relief�alve Air Inlet Check Vaive
Inival Test DGClosed Closed Ti�ht ed at Opened at nsid
Ti�t Leal:ed o (��sid osid
R.P- �,�nsid � �
Leal:ad o Did not Opea ❑ Leal:ed O
Repairs
aad
Materials
Usod
Test Aft,er DGClosed Closed Tight o Opened at Opcaed at _nsid
Repair Tight � esid _nsid
RP sid
The above is cerafied to be true.
Firm N���I�c� r.r�,os rt CatiSed Testa�r✓��fic��'
Firm Address�°�d/�n7 *aa�x���,:���'aF'�' Cert. TestGr No.� �'�$�'� Date � /
Gauge # �c�C��D�'S L�
llate last accuracy tested,��,�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy