2015_0611 (2) C�iECK ONE:
IRRIGATION DOMESTIC FIRELINS
BACKFLOW PREVENTTON ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: f � �1 �� ( r � S -S� �`>e � � C v t 1' �' r a i �(
'Ibe baci.�flow preveation asscmbly detailed below has beea tested and maintained as required by TNRCC =
regulations aad is ccrdfied to be operating withia acceptablc parameters.
TYPE OF ASSEMBLY
�. Reduced Pressvre Principle e Pressure Vacu�Breakez
❑ Double Check Valve o Amnosphere Vacuum Breaker
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Manufacuaer ��`:� �- � � Siu � Z
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Modei Number �-� � ��1 � � Located At f ��'�' ,� ���� � '��
Serial N�ber �L Z ! ���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check v alve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti,Pht Iffi O�ened at Opened at _nsid
Tight �ffi. Leal:ed o �. • ` sid �sid
R.P-�'�Dsid ;-
I,eal:ed ❑ `� �� Did aot Opea o Leal:ed D
k
��t�
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Materials
' Used
Test After DC-Closed Closed Tight o Opeaed at Opeaod at i sid
Repair Tight o flsid osid
RP sid
The above is cectified to be trve.
Firm Name � �, , -� e .e ����--i��-�t.:,, . t �� � Certifiod Testa ��e� ,� � , 7 G��..,,� ��.-,�� �,�r_ . ,
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Firm Address ' '1�< . �" ��,,:> ;z. �� ���.;,w5 r�. Cert Testc No. �t � �_ � ���� � 5���� �- , 1;�
Gauge # �:� '�'S �,
llate last accuracy tested `-? t i S
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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