2015_0212 (5) C�iECK ONE:
IRRIGATION DOMESTIC �/" FIftELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
, ,...
LOCATION OF SERVICE: i Y�1� � —T�C� C.��'<-I�J►'1 �-'�;r"��_� I 1� � ���� �L�
The bacl�low preveation asscmbly detailed below has been tested aad maintained as required by T'NRCC
regulations and is cercified to be operating within accrptablc paramcters.
TYPE OF ASSEMBLY
� Raiuced Pressure Principle � Pressure Vacu�Brealcer
� Double Chxk Valvc o Atmosphere Vacuum Breaker
Maaufact�er
��-5 s� -'� `"
S� -����
Model Iv�ber ��� �� � � , Located At 5 1 Y>'t=i Cr'� r►�C�-�=+ri=�'�-f r�.���:. ,
Scrial Nimmba vt� � �`��?
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check v alve Assembly
lst Check 2nd Checl: ReIief Valve Air Inlet Checic Va1ve
Inival Test DGClosed Closed Tight ed at Opened at �sid
Tight Leal:ed o sid _�sid
��j � �j� � S�a o ..�� �
Dia noc Opea o L,eal:ed o
�P�
aad
Mat�erials
Usod
Test Aft,er DC-Closed Closed Tight o Opeaed at ppeaed at _osid
Repair Tight O �sid nsid
RP sid
The above is catified to be true. . „
�'� 1,� �_� '? -! �t.r;
Firns Name �c��I� '►rv-�C,�'���i�-�, e r;l CeRifiod Tester �h.� �i �r � �i� �-��1.-.5�`�!
r �
Firm Addrass �'��`S I � '� 5� Cert. Tester No. ��'�'J���S Date� �.S
,
�,�tiH�,.�t -r,_t , �: ,- _�'""� ,���;>,'� �
Gauge # �.�.� II ��`?f
llate last accuracy tested � � C�'"'��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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