2014_1010 C�IECK ONE: °
IRRIGATION DOMESTIC FIftELINE /�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
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rr�OF Pws: CITY OF COPPELL
PWS I.D. #
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LOCATION OF SERVICE: ._� _.� ,, C I�,,Ir-�1 C�L t� � �;
The bacl.�flow preventioa asscmbly detailed below has bcea tested and m�ta�ned as required by TNRCC
re_suladons and is certified to be operating within acceptable paramtters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuimi Breaker
_ '�' _-- Double Chcck Valve > , � o , Atmosphere Vacuum Breaker �
k =- r : . , _ ___ _
Maaufactsaer /-� r�-�..�� Siu ��
Modei Number �":�.C �-.� � Located At 1 C:� �o\c�Y,�a.�.
SerialNimmber �')�;�,5 �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
ist Check �nd Checl: Relief Valve Air Inlet Checic Valve
Inidal Test DGClosed Closed Tight � Opened at Opened at osid
Ti�t ❑ Leal:ed ❑ nsid _osid
����� RP- Z '� Dsid � c._�
I,�;� ❑ �'` Did not Opea o L,eal:ed o
RePairs _
and
Mataials ;
� � �� �.Jsod � �� � � � � �, i� � � ��
� Test After DC-Closed Closod Tight o Opened at Opeaad at �sid �
Repair Tight a �sid nsid
RP sid
The above is certifiod to be true.
Firm Name�Y�i e.�r�l c� ��<.� ���e r}�ir,„- CC�Cd T
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Firm Address��� ,�,r i���:�1,.�,..�� �x �S!LS` Cat Teste No.�`�lSS�Z� Date Ju-� I t�- I� �
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(�suge # C�I(��-)`Z`r l�� ��
Date last accuracy tested �,_2 �- �y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy '
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