2014-0317 C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE x
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �'�� r� �� ��� '�
The back�flow prevmtion asscmbly detaile� below has beea tested aad maintaiaed as requircd by TNRCC
regulaaons aad is cerdfie�to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Rcduced Pressure Principle C Pressure Vacu�Breaker
� Doublc Check Valve o Amiosphere Vacuum Breaker
� y
Maaufactiaer �� S Siu /
Modei Ivimmber �� ��u/ Locaud At /��� ��r�� ��
Serial N�ber L/'f �T 7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Check Valve
Inival Test DGClosed Closed Ti,Qht 1� Opeaed at Opened at nsid
Tight o Leal:ed 1'��� o __Dsid osid
RP-_psid
�;� � Did not Opea o Leal►ed �
�P�
and
Materials
Used
Test After DC-Closed Closed Tight o Openod at Opeaed at �sid
Repair Tight o �sid _osid
RP sid
The above is certified to be true.
Firm Name l����c i�- /"//�� Catificd Testa 1�� ��� ���/� ��
Firm Addr�ss ��'��`�X ��7���'�T� Cert. TGster No. �/°�'Cc�7�'> �� ��"����
Gauge # G�G y/��G
llate last accuracy tested � �l�-�y
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy