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2015_0212 C�IECK ONE: IR.ItIGATION DOMESTIC � FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT' NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: ��4�'S �J`�� `�� `�i';� ��I �� SC�I �'( The bacl�low prevmtion assembly detailed below has beea tested aad maintained as required by TNRCC reguladons and is certified to be operating withia acceptable parameUers. TYPE OF ASSEMBLY �'` Reduced Pressvre Principle ❑ Pressurc Vacu�Breaker � Double Check Valve ❑ Amiosphere Vacuum Breal:er 1 r� Maaufactiaer �rV�-�-�� Siu r� � Modei Ivumber (��_�`�`� � r� � � � Located At ��'1�' ��'�,�t.� � Scrial Nimmber � r�-� � �� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly lst Check ?nd Checi: Relief Valve Air Inlet Check Valve Initial Test DGClosed Closed Ti�t ed at Openod at osid Ti Leal:ed ❑ C�psid osid �� 1:��-�� S�a �� I,�;� ❑ Ihd not Opea O Leal:ed � RePairs and Mataials Usod Test After DGClosed Closod Tight o Opeaed at Opeaod at �sid Repair Tight ❑ osid _�osid RP sid i The above is certified to be true. � ` f , r Firm Name �� 1� �'�L' �_�1�111 � ��C I CC[tlfied TCSta � 1 �I + �''►1�'° L�'vf.S`�'- `.-% Firm Addc+ess c��l;�� I� +��'�,� S�` Cat Teste No. �� _? �. Date�=f ,� � �.��,�n c� ��'��; �,`{' -�"j, -7�'b c�,.�.5� Gauge # f�..� I! -�;;.� �?' �- llate last accuracy tested � �' �``� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy _ _ _ . , � _ _ _