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2014_0615 C�IECK ONE: IR.RIGATION DOMESTIC FIRELINE BACI47.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT ' � rrAME OF Pws: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: �'��' �`��-�� ; �'�' r The bacl.�tlow preveation assembly detailed below has beea tested and maintained as required bv TNRCC reguladons aad is certified to be operating withia acceptable parameters. TYPE OF ASSEMBLY C Rcduced Pressure Principlc ❑ Pressure Vacuimi Breaker ;�.., Double Chxk Valve ❑ Atmosphere Vacuum Breal:er _. ` , �� Maaufacturer tN"�� S� . �c'��7 #� � �-T� Locaud At �r,��.� `;,�� j`}' �rt��C �.'%°�j'� Modei Number Scrial N�ber ��'� ��`� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Va1ve Assembly lst Check 2ad Checl: Rdief Valve Air Inl�t Check Valve Inival Test DC-Closed Closed Ti;ht � Opeaed at Opeaed at osid Ti�t ❑ Leal:ed a �sid osid R.P-_psid �;� j� Did not Opea o Leal:ed � } � �P� �.t �c>��a t t�t��'" � � �c su�r�F-t�;_ Mataials ��m�� Used j��k�.��:C'. :._ Test ARet DC-Closed Closed Tight �� Opened at Opmod at _ __flsid Repair Tight � �sid osid RP sid The above is cerufie�to be true. .� __. ._��._�.___`~ _ � �� .. �4� �� S � �1 Firm Name � ��c•� j��►�t` �n r Catified T '��",n�_ ��v�---. , �.� ',1 } r� i a.�� ,� ._...,_......r _ 9 �,ji A' < � ��z�.� � � ._�bzg �" ., _ G 0� ��1 w Firm Address '��' /��";'� ��2 � �.� Cert. Tester Na � 7 Date_ ' Gauge # C'�fs,��; �t , llate last accuracy tested i f � � ' �3 White - Customer's Copy Yellow - City Copy Pink-Tester's Copy _. ,. . _ _ _ , s,��w�