2013-1120 (2) C�IECK �NE:
IRRIGATION DOMESTIC FIftELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
. ., _ � . d
LOCATION OF SERVICE: O I �QS� I �1-1 ��1'� � �;��f•Ul�i�r
The bacl.-flow prevmtion assembly detailod below has beea tested aad maintained as required by TNRCC
regulauons aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Rtduced Pmsure Priaciple � Pressurc Vacu�Breaker
;�; Do le Check Valve o Amiosphere Vacuum Breaker
�r
Maaufact�uer Siu
Model N�ber �� �Q�'r� Locaud At � `
Scrial N�ber �1�' '"� �'�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Vaive
'ual Test DC•Closed Closed Ti,Pht ❑ Opened at Opened at nsid
_, Tight ❑ Leal:ed o _�sid osid
RP-_psid
�((� I,�;� ❑ Did not Opea o L,eal:ed J
�� ���
� .��
Materials
Usod
Test ARer DC-Closed Closed Tight o ppeae�at Opeaed at _.nsid
Repair Tight o nsid _,vsid
RP sid
The above is catified to be true.
Firm Name��C �� � (��_ Certifiod Teste �C��l V�� t�i(r i�@,Q,Y
Firm Address Cat Te.ster No.� Q � Date �o � �1�-
Gauge # �� ��'
llate last accuracy tested �� /� �(�j
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy