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2014_0521�y� � . . . . . .. . . 1 C�IECK ONE: � IR.RIGATION DOMESTIC FIRELINE / `� BACI�'LOW PREVENTION ASSEMBLY TES?AND MAIIV'I'ENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: �`�� f� 1��,Y�� (��� � T3e bacl�low prevmtioa asscmbly detailed below has beea tested aad maint�C� as nquired bv TNRCC regulanons and is cerdfied to be operating within acceptable parameters. TYPE OF ASSEMBLY e Reduced Pressure Principle C Pressure Vacuimm Breaker � � __ - � _,: .I?oublc Che�k VaIve , ;_ �_ �. _`-_ Am�osphcre Vacuum Breaker ' . - - , _ _ __ _ _ � Maaufact�er �,��,,:,�, Siu _ 1�� ` Model Ni�ber ��.'�C7 Located At �n�^-5 �` ,�1 r�Y-.�e.._� Scrial Nimmber C��?��fifi�l REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSiJRE VACUUM BREAI�R Double Check Valve Assembly lst Check 2nd Checl: Relief Valve Air Inlet Check Vaive Initial Test DGClosed Closed Ti�ht �'` Opened at Openod at csid Tight Leal:ed ❑ �sid __osid ���`� RP- I�sid -� . lo Leal:ed o �`" Did not Opea o Leal►ed o RePairs and � Materials ' � M �� I � r Test Aft,et DGClosed Closed Tight o pp�aed at ppeaod at _osid ' Repair Tight o _�sid __nsid �! RP sid ' The above is certified to be true. Firm Name L��o�me�-�a`�c�nr`��,t� �� - Catified T t.j�� 1�1 YY�Gc�U`�� `'>i Firm Address 1ti%ax�.1-��.r1��. .�-1� ��f�� Cert. Te.ster No.�� a � .Z 3 Date - �- �' Gauge # S��!I`i��l��- llate last accuracy tested �t 11- �� White- Customer's Copy Yellow - City Copy Pink-TesteNs Copy _ _ , �