2015_0626 ��
C�IBCK ONE:
LRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �Q �S 5. b-Q,�� 1 � ^�e R-� .
The bacl�]ow prevmtion assembly detailed below has beea tested and maintain� � nq�� by TNRCC
regulauons and is certified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressurc Priaciple e Pressure Vacuimm Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Maaufactzaer �U��S Siu r S'�
'"'�a- Q l
Modei N�ber Locaud At bv�L►L �'c..l\
Scrial Nimmber ��i��S �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check v alv�Assembly
lst Check 2ad Checl: Relief Valve Air Inlet Checic Valve
Inival Test DC•Closed Closed Ti,ght � Opened at Opeaed at osid
Ti ,� Leal:ed ❑ ,�. .8 ,.psid nsid
�/��/�s ��S�d �.o �
� 0 Dia nac open o Lea1:�
�P�
and
Materials
Used
Test ARer DC•Closed Closed Tight o Openod at Opeaod at _nsid
Repair Tight 0 flsid osid
R.P sid
7he above is certifiod to be�ue.
Firm Name �a���-o;� Ca.-v►r+►��c:c�1 _ Cettified Testa ���" �`''�t-�
L�� S. (e,��`� 2x,��re�y„c-y �� Da1�3�1
Fum Address �%+�-:+��•;� T�_ Cert.Tester No. g� � Date
(�suge # �3 I a 3�3(�
llate last accuracy tested 3 /3 ��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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