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2015_1022 C�IECK ONE: ;� IRRIGATION �` DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # � LOCATION OF SERVICE: c`-' � `"' � ;'%--��jJ�t� +/ The bacl�low preveation asscmbly detailed below has beea tested aad maiatained as require� bv TNRCC regulauons and is ctctified to be operating within acceptable paramcters. TYPE OF ASSEMBLY C Reduced Pressvre Priaciple C Pressure Vacu�Breaker �"A Doublc Check Valve o Amnosphere Vacuum Br1eaker � -�-�'� Maaufact�aer �.rd� � �- �j=, � Siu `' ! Modei Number _� ' f-' Located At �' �`,`"v� �*° `��r.� Serial N�ber �'� `�y�.-;C�_� � <-:� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R Double Cbeck Valve Assembly lst Check 2nd Checi: Relief Valve Air Inlet Check Va1ve Inival Test DGClosed Closed Ti,pht � Opeaed at Opened at �id Ti�i �' c: Q Leal:ed ❑ _�sid nsid RP-_psid �,�, � I,�;� � Did aot Opea o Leal►ed ❑ �� and Materials Uscd Test After DC-Closed Closed Tight a Opened at Opeaed at �sid Repair Tight o osid _osid R.P sid The above is certified to be tcue. .-- � . � ;.� i' ' ''�r'�`� Certifiod Testc �� '',%'< <`� ✓<<��'C � ��-��-,; '��.- Firm Name _ _ ,�. ,� t_�,� �-� A � , l:-<.,�..� r� _ ; ;��;;� , �_ Firm Addres.s _S� �1�;�`;�� 1�`��Cat Tester No `��> �'f--' Date f�, . �iS1Ig@ ��-��C��'+: �E � .'i_ c , ,r llate lsst accuracy tested °:.�',/�,r ,�''> � White - Customer's Copy Yellow - City Copy Pink-Tester's Copy