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2015_0212 (2) C�IECK ONE: IRRIGATION DOMESTIC �� FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR? NAIv�OF PWS: CITY OF COPPELL PWS I.D. # LOCA'FION OF SERVICE: 1� � r�� '� 4`„� `� ��i�::k � X ��;1�1`7 The bacl�low p=evmtion assembly detailed below has beea t�sted aad maintain� � nq� bv TNRCC reguladons and is cerdfied to be operating withia acceptable paramete�. TYPE OF ASSEMHLY �'./ Reduced Pressure Principle � Pressurc Vacuimm Breaker ❑ Double Check Valve ❑ Amiosphere Vacuum Breaker i/ '' Maaufactiaer �`�'` �� Siu /v� Modei Nimmber (�� Located At ��rn�- �+�� .,�k�� f/�i=�'r`� s«��N�ba '��Q 0 0 � � �.�F'�Y�-�-, .�..}; :�� REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE VACUUM BREAKER Doubie Check Valve Assembly lst Check 2nd Checl: Relief Valve Air Inl�t Checic Valve Ininal Test DC-Closed Closed Tight ed at Opened at _nsid Ti,�t Leal:ed o O �,��sid _osid �-r�.��' �j sid ❑ pp� o Leal:ed ❑ �r � Did not �P� and Materials Used Test After DC-Closed Closed Tight o Opeaed at Opeaed at _�sid Repair Tight o �nsid _,osid R.P sid The above is certified to be true. n x � Firm Name,�Q I�1 ►'�..�:�►a�r i�� _ Certifiod Teste �� I r�� rY�i �.�t� �,� ��. �� Firm Address � ��S,�,� ��s l z� 5�" Cert. Taster Na � Date a�' __ �� _�� -Y"��t�� 1 f f�, � {ti� TX, 7�� Gauge # t'��)/ ,��-y c�,. llate last accuracy tested � " � " l -�j White - Customer's Copy Yellow - City Copy Pink-Tester's Copy i _ _ _ _