2014-0317 (12) C�IECK ONE:
IRRIGATION_� DOMESTIC FIRELINB
BACKFLOW PREVENTION ASSEMBLY TES?AND MAINTENANCE REPORT
N�ME oF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 3 � �
The bacl�low prevmtioa assembly detailed below has beea tested aad maintained as required by TNRCC
re�ladons and is cerdfied to be opera�ng within accrptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressvre Priaciple e Pressure Vacu�Breaker
�- Double Check Valve ❑ Atmosphere Vacuum Breal:er
Manufac�aer � �c o Siu � !�
Modei lvumber �(�'��/ Located Ai �����-� n•��-�c.� �',"� ���
Serial N�ber V v����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Cbeck v alv�Assembly
lst Check �nd Checi: Relief Valve Air ldet Check Va1ve
Inival Test DGClosed Closed Ti�t � Opeaed at Opened at �id
Tight � Leal:ed 0 vsid _nsid
RP-�psid v
�;� p �� Did not O pea o L,e a l:e d �
�P�
aad
Mateiials
Used
Test Aft,er DC•Closed Closed Tight a ppened at Opeaed at __.�sid
Repair Tight ❑ �sid �sid
RP sid
The above is certified to be true.
Firm Name�'�'is�a �i.^e �f�s Cadfiod Tester ./"►/� �� I I,�r�s
Firm Address -O. �i�J ,� � <� � ' ,�Cert Tester No. � � Date �'� ')�
� X
cauge # p�,c�-( 1�Gl +�
Date last accuracy tested�r - ��'
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy