2014_1217_RPZ (2) C�IECK ONE:
IRRIGATION DOMESTIC � gI
RELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
rrpME OF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: {�Ver1 d�,'S �°�� ,�. �acgc,f�w� ����,1.
y ,
The bacl�low prevmtion assembly derailed below has bem tested aad maintain� � nq� bv TNRCC
regulaaons and is cerdfied to be operating withia acceptable parametreers.
,/ TYPE OF ASSEMBLY
lg''� Reduced Press�ure Principle � Pmsure Vacui�Breaker
❑ Double Check Valve o Atmosphere Vacuum Brea�er
Maaufactiaer �?�S Siu
���
Model N�ber L��� �Q� Located At ��C� O� S�e �'�` ��ec �a�('
Scrial N�ber �� ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R �'
Doubie Check Valve Assembly ',
lst Check 2nd Checl: Rdie{Vaive Air Inlet Check Valve
Inival Test DGClosed Closed Tight o ed at Opeaod at nsid !
Tight o Leal:ed o �psid ,_osid '
��gS R.P- �'�-Dsid $,�
I,eal;ed a Did not Opea ❑ Leal:ed �
RePairs
and
Mataials '
Usod '
Test Aftet DC-Closed Closed Tight a ppeaed at ppeaod at _�sid
Repair Tight ❑ Dsid _osid
RP sid
The above is certifiod to be true.
Firm NameA��+����o+-.J �,�,e�►s� Certifiod Testa�c`51�Pf�C_ L . ���`"t r"��f1
Firm AddRss��.�l 5�,�1?-d�r4� w7.�" Cat Tester No.�BQ Od f G►a Cv I Dace�a- r 7-�y
CnQ'vJ` •
GBu�e # 05 R'�I O(�3
llate last accuracy tested �` ��S' �`�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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