2015_0618 C�IECK ONE: ��` � � " �� J I�/`�l l
IRRIGATION DOMESTIC FIRELINE
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BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAN�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � '���
The bacl�low revention asscmblv lde�o�'�eiow has baa tested�� maintained as required by TNRCC
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reguladons aad is ' ed to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressvrc Priaciple e Pressur�e Vacui�Breaker
^ Double Chcck Valve o Amnosphere Vacuum Breakerr
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Maaufact�er �,.l��1 �� Siu �/'L
r �-' � r
Model Number v� �� � Located At ��1 !/1 � �C �
G1 � \
Serial Nimmbcr �i� `�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: 'ef Valve Air ldet Check Valve
Initial Test DGClosed osed Tight e� Opened at osid
Ti�ht a Leal:ed o �sid _nsid
�� � RP-.�psid p�'
�� I,eal;ed ❑ D '� Did aot Opea O Leal:e� J
�P�
aad
MatzriaLs
Uscd
Test Aftet DC•Closed Closed Tight o Opeaed at Opeaed at __nsid
Repair Tight o osid nsid
RP sid
_ The above is certified to be true.
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Firm Na�e � � Catifiod Testa
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Firm Addc+ess ��'�Cat Testa No.� ��� _Date , � �
(�suge #0 S����
llate last accuracy tested ���' S
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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