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2015_0611 C�iECK ONE: , � IRftIGATION DOMESTIC � FIRELINE BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: I�,�� ( .'� �<� �- 5� ��-e �� �-' ,'�'p' ' j `� The bacl�low preveation assembly detaile� below has beea tested and maintained as required bv TNRCC � regulanons aad is cercified to be operating withia acceptable parameters. TYPE OF ASSEMBLY l� Reduced Pressure Principle ❑ Pressurc Vacu�Breatcer ^_ Double Chcck Valve ❑ Atmq�phere Vacuum Breal:er �/ � Maaufact�uer a"► � ( � � `` � giu �I�%�Pr�• �y � Modei Ivumber ��7`S X t— Located At l'�-e �� •- ��'G� ✓* Serial N�ber ���'1 �Z-� b � � REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valv�Assembly lst Check 'nd Checl: Relief Valve Air Inlet Check Valve Inival Test DGClosed Closed Ti,,�.ht � Opened at Opened at nsid Ti�t� `� � Leal:ed o . ��sid osid R.P-_psid �;� ❑ �' �' Did not Opea � Leal:ed � a •r"Y�11 S � Materials . U� Test After DC-Closcd Closcd Tight a Opened at Opeaod at __osid Repair Tighi � nsid osid RP sid The above is catifiod to be�ue. � Firm Name �`t�., ' ���l ►-,,• E.�� ��t ��c�.I Certifiod Testa �c.�, n �� (. c� r..--�- ��,-, ��.�-� ,�✓-� �" � Firm Address f� S�:..� b� ���� , r�4-� �, iz �> �,.. � ,�`'Ceit Tester No. 1:•'�� � E ti 3 S-�Date �n. 1�' S Gauge #� j i ., �� Date last accuracy tested �"� � ` � � White - Customer's Copy Yellow - City Copy Pink-Tester's Copy i