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2015_1027 C�IECK ONE: IRRIGATION �„r'"�� DOMESTIC FIRELINE BACI{�'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAIvIE OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: � � �:�����=�� .t ���� � >- ����.; � The bacl�low prevmtion asscmbly detailed below has beea tested aad maiatained as required by TNRCC re_�ulations aad is cerdfied to be operating within acceptable parameters. TYPE OF ASSEMBLY C Reduced Pressure Principle C Pressure Vacui�Brealcer �'` Double Check Valve ❑ Amiosphere Vacuum Breal:er Maaufacuaer 'r>, ' ;� Siu +�``l Model Ivumber `�c�' Locaud At ,� ���,~_ � �� {�-% , Serial N�ber 1'� `� <--'e�5'' ! ti d� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly lst Check 2nd Checi: Relief Valve Air Inlet Check Valve Inival Test DGClosed Closed Ti,,P.ht a-" Opened at Opeaed at _nsid Tight�, � �- Leal:ed o csid nsid RP-_psid �;' ! L,�;� o Did not Opea o L,eal:ed � �P� and � Mataials Usod Test After DC-Closed Closod Tight o ppened at Opeaed at _�sid Repair Tight o �sid _,_osid RP sid The above is catified to be true. �F� �f � ._ , ,. . .. � Firm Name .� °'�'�� Certifiod Testa 1" � f� �'�'f� {:=� ��., d- � � � ,' (r��,�,� s;:����? �✓_-��.�.i � Firm Address �,�r `%` �' �ert. Testa No r�c'`; j._J D� 1�.: � ;� ,;� Gauge #cs";!�+%��`�"I !fa�� ? llate last accuracy tested 7 /��' �j� � � White- Customer's Copy Yellow - City Copy Pink-Tester's Copy