2015_0514 , �� :�
e. �
C�iECK ONE: , .
IRRIGATION_� DOMESTIC FIRELINE
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
- LOCATION OF SERVICE: /�I �v�-,.f:�.,? C �
The bacl�low preveation asscmbly derailed below has beea tested and ma�nta�n� � nq�� by TNRCC
regulauons aad is cetified to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
e Reduced Pressurc Principle e Pressurc Vacu�Breaker
� Double Check Valve o Aunosphere Vacuum Breaker
�� / ��, '
Maaufacuaer ����'Gi�: � Siu �
�,
Model Ivumber �'.}�� Located At �-��� �� �� �����'��i"
Serial Nimmber �i� ��L�.-���
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAKER
;
Doubie Check v alve Assembly �
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti,Ph� Opened at Opeaed at osid �
Ti�t, Leal:ed ❑ �sid osid
,� R.P- ��'' sid
/,,;s>F� �`� o Did not Opea o Leal:ed o
�P�
aad
Materials
Usod
Test After DC•Closed Closcd Tight o ppeaed at Opeaed at _,_nsid
Repair Tight o �sid osid
RP sid
The above is certified to be true.
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Firm Name f��'�'_``�;�� �ir.fy �--�, Certifi�Testet _� '
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Firm Address.��`f � //<, � -���;;,�1✓..�. Cert. Testc No. ��v�` '� `- Date �
G`
Gauge # ���(J/���l
llate last accuracy tested �,2-�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy