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2015-0910 C�IECK ONE: IRRIGATION DOMESTIC FIRELINE ✓ BACI�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR? NAIv�OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: .3:-�o -S �r�`� �',rr,-> ,�"- �L1'�,,�'-�,�' 'Ibe back�flow preveation asscmbly decailed below has baa tested aad maintained as required bv TNRCC regulauons and is certified to be operating withia acceptable parameters. TYPE OF ASSEMBLY e Reduced Pressure Principle e Pressvre Vacu�Breaker Double.Check Valve o Atmospherc Vacuum Brealer - _ _ . _ �. _ _ _ , Maaufactsaer ,��,� � s Siu -�.�� Modei Number l 7 S�' Locaud At �� -,j f,"�f-7'�' Serial N�ber `/S7 ��y�/�� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R Double Check v alve Assembly lst Check '-nd Chec1► Relief Valve Air Inlet Checic Valve Inidal Test DGClosed Closed Ti,Aht - Opeaed at Opeaed at osid Tight �T Leal:ed ❑ __osid osid RP-�sid � ,; r;.. Leal:ed � / � Did not Opea o Leal:ed � �P� aad Mataials Used _ _ Test Aftet DC-Closed Closod Tight o Opened at Opeaed at _flsid Repair Tight ❑ nsid _._,Dsid RP sid The above is carified to be t�ve. /�� Firm Name �-, , �, ,'��= � Catifiod Testa � ��-�-` �-"=� �_... -a- .� ��._ Firm Address�� rr; _� - ,�=�'� Cert. Tester No. �: /,�'f � /%"��Date � r. .�f��,�;� T} _.J,�� Gauge # ,r;.��h; ;�_ llate last accuracy tested r '`' ' White - Customer's Copy Yellow - City Copy Pink-Tester's Copy