2013_1205 C�IECK �NE: -
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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LOCATIOIv'OF SERVICE: �� �� �. f�/q 2 �-/� � �
'Ibe bacl�low prevention assembly derailed below has beea tested and maintaiaed as requiizd by TNRCC
rcgularions and is ccrdfied to be operating within acceptablc paramtters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principle C Pressvre Vacu�Breaker
^_ Doublc Check Valve ❑ Amnosphere Vacuum Breaker.
Maaufact�er � `�� Siu -��y
Model Number �S� Located At ����
Seriai Ni�ber /�� " �(p��7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Cherk v alve Assembly
lst Check lad Checl: Reiief Valve Air Inlet Check Valve
Initial Test DGCloscd Closed Ti�t ❑ Opened at Opened at osid
Tidit ❑ Leal:ed 0 �sid osid
RP- � sid �,�
Lcal:ed o Did not Opea O Leal:ed �
�P�
and
Materials
Used
Test After DC-Closed Closed Tight o Opeacd at Opeaed at �sid
Rtpair Tight ❑ osid nsid
R.P sid
The above is certified to be true.
Firm Name
/4/U� Certified Testa �� �N;�i4��^
Firm Address � �JC L (_!�o-�T�`v Cert Tester Na ����Z Date T � 7 ^ � �I
c�suge # ���-g l�i�-� 3�2� >�/
llate last accuracy tested �Z � ��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy