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2014-0317 (16) C�IECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REPOR? NAN�OF PWS: CITY OF COPPELL PWS I.D. # LOCATTON OF SERVICE: � �� T^e.e�:��' �rL'U,� The bacl�low prevmtion assembly detailed below has beea tested aad mainra�n� � nq�� bv TNRCC regulations aad is cetified to be operating within ac�eptable parameters. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacutmm Breaker � Double Check Valvc o Atmosphere Vacuum Breaker �ll Maaufacaaer ' Siu —- Modei Nt�btr �C�'� Located At !v W C';.:r,.�r ir� i�u�� Serial Nimmber � � 0 G 6 �� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUiJM BREAI�R Double Checic Valve Assembly lst Check 2nd Checi: Relief Valve Air ldet Check Valve Iniaal Test DGClosed Closed Ti,�ht � Opened at Opened at nsid Tight �d' Leal:ed o csid osid RP�sid �� ❑ �+ �' Did aot Opea o Leal:ed o �P� and Mataials Usod Test ARer DC-Closed Closed Tight o ppeaed at Opeaod at _�sid Repair Tight ❑ �sid __�sid RP sid The above is certified to be tcue. � lFirm Name '�� '�l� J��j Certifiod Testa /"I,� l`�' ,``'�'� Firm Address�7 B tY� �7�17 1�1)�x.�� _�y%�ert. Taster No. �� Date �- •-, `� �g� � ��c�-j 1 �9� llate Isst accuracy tested �3- ' �� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy