2014-0620 (10) C�iBCK ONE:
IRRIGATION ✓ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:�M��- �1 v��t r r�, C�✓,� ��-�`'' S I r{ � �.>u.}`
The bacl�low prevmtion asscmbly detailed below has beea tested aad mainta�n� � nq�� bv TNRCC
regulations aad is cetified to be operating within acceptable paramcters. '
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressure Vacu�Breaker
� Double Check Valve ❑ Atmosphere Vacuum Breal:er
Maaufact�er ��� � 5 Siu �
Model Number L ,� �u 1 /1-� 1 Located At Y'-� c�*� �,�� ��- r �� I�t c��
Seriai Ni�ber �� 1 � k �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checi: Relief valve Air Inlet Checic Valve
Inidal Test DGCloscd Z- 1 osed Ti�ht Opeaed at Opened at esid
Ti�t Leal:ed ❑ Dsid nsid
RP-_,psia l lo
L,eal;ed ❑ Did not Opea � Leal:ed �
Repaus
and
Materials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair Tight ❑ nsid nsid
RP sid
The above is catifiod to be true. �
�}1,%�t,,� ��a ��� t-`� t:.�:d.�.f �.,�:-�-'�trtifiod Testa �'�, `:� .�°�' 1� �9 ti^t��n�.,�
Firm Name —
�
Firm Address � ;,` !��--'� -�`� � '��` _.� Cert. Testa Na ���'�`��'�� Date��Z'�_�`.�"
t _-�,-. a
�i��`',1 �sc"!b"; 's'if �i1r1<. r �!'' r�
(3auge # �..���� r ' ``t :: ,
�
Date }ast accuracy tested ,•�' ��:��'-` ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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