2014_1111_RPZ C�iECK ONE: � � z
IRRIGATION DOMESTIC X FIRELINE
BACKFI.OW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # /h�r�F s�'��{ ,� $�y
LOCATION OF SERVICE: �0� AJ. A�h T4fP raI•
The bacl�low preveation asscmbly detailed below has beea tested aad maintain� � nq� bv TNRCC
reguladons aad is cerdfied to be operating within ac�eptabla parameters.
TYPE OF ASSEMBLY
�'d Reduced Pressure Principle e Pressurc Vacuimm Breaker
❑ Double Check VaIve ❑ Atmosphere Vacuum Bnaker
r
Maaufactiaer ►�,k�'�� Siu l.L
Model Ivumber �4 y Located At �Sk�/'y 41��r .TJ/I,�
Serial Nimmber
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checi: ��{��ve Air Inlet Check Valve
Inival Test DC-Closed Closed Ti,,P.ht � Opeaed at Opeaed at _osid
Tight ❑ Leal:ed ❑ �sid _osid
��� RP-_�psid
L,eal:ed Did not Opea o Leal:ed �
�� ;ns4rclle� # I Cl�rck �� �a��e,
��� e„� c����+�� uwti � �'/kr�,
Mataials r[{��r�r
Used k'�•
Test Aft�er DC•Closed Closed Tight `� Opeaed at Opea�at _�sid
R�pair Tigt�i S � 2'P psid osid
f'4'sf Rp � sid
The above is certified to be tcue.
,qt� fP� w;r1��r C,
Firm Name Certifiod Testa �►'�uh
Firm Adaress 4 sy�' nk,�f���q�e V,t w �n • CeR Tester No. �!°�'/�6/l) Date (�`�� `�
��• w�rf7� 1�• 7�iuy
Gauge # 0!13!(/3
llate last accuracy tested I�� (U -/y
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy