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2015_1013 C�IECK ONE: IR.RIGATION � DOMESTIC FIRELINE �_ ,_, ,�...,�. ._,.____.k.�._.,.�.. w... . __ _ ,..-.�... ._�.,. ._,..�.e. . _ �:.� e.� � ,r�...... BACKFLOW PREVENTION ASSEMBLY TEST AND MAINT��iANCE RE�OR�`__. _ . NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: ��' � " > �' i ��i L= 'Ibe bacl�low prevtation asscmbly detailed below has beea tested aad maintain� � nq�� bv TNRCC regulations and is ceitified to be operating within acceptable paramcters. TYPE OF ASSEMBLY C Reduced Pressure Principle � Pressure Vacu�Breaker �-�''�� Double Check Valve o Atmosphere Vacuum Breaker ,, Maaufact�uer l �.�� ' ' �� 3 L� t�i o r"-� a $1ZC f Model Iv�ber `� .;> Locaud At t' � '�k � ' ,r'`;� � � .�� Scrial Nimmber i'� <>_�� , 7 � �..__ L.}_ �; REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER - Double Check v alve Assembiy ' lst Check 2nd Chec]: • Relief Valve Air ldet Checic Valve Inidal Test DC-Closed Closed Ti;ht Opeaed at Opened at nsid Tight ,.�` Leal:ed ❑ Dsid nsid RP-_psid � �� ❑ `'�` � Did not Opea o Leal:e� � �P� and Materials Used Test ARer DC-Closcd Closod Tight a ppened at Opea�at _nsid Repair Tight o osid osid R.P sid The above is carifiod to be true. Firm Name `` .� -` r`�+�`��_ Certified Teste �'�%' . �% c. < 1 ��•,� •° �. . ;� Firm Address �� r � ��L� 4 t;;��`�f� � �,�-' Cert Teste No �'" `` 'a Date /f=_%.O ..� _ Gauge #�:: � '�,/Cf `�' � Date last accuracy tested ` � �� ,- ' White - Customer's Copy Yellow - City Copy Pink-Tester's Copy