2015_0701 (2) C�IECK ONE:
IRRIGATION ll, DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: � I� �A��.r�+�hi
The bacl�low prevmtion assembly detailed below has beea tested aad maintained as required by TNRCC
re�ulanons aad is cerdfied to bc operating within acceptable paramctars.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressvre Vacui�Brcaker
'�, Double Check Valve o Atmosphere Vacuum Breal:er
Maaufactsaer �..� Siu � +f
Model Ivumber ��(:� Located At � ��A�E, Z� Ar�O� +�.I :c�. �'�4 S�
Serial N�ber �'����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Doubie Check Valve Assembly
lst Check �, 2nd Checi: . Relief Valve Air Inlet Checic Valve
Initial Test DGClosed Closed Ti,Pht � Opeaed at Opened at nsid
Tidit �`1 Leal:ed o nsid osid
RP-__psid
�;� � Did not Open � Leal:ed O
�P�
and
Mataials
Used
Test Afttr DC-Closed Closed Tight o Opeaed at Opmed at _osid
Repair Tighi � csid _nsid
R.P sid
'Ihe above is cesdfied to be we.
J,� j� \ �
Firm Name �DZ712�'�i►�t �J'v�1 tc.���J Certified Testa I ���i� �P,I�C�
Firm Address iD�=� : � �II '��, Cert. Tester No.gf Q�7iCv��1 Date I �J�
Gauge # ����U`G�`'�'.�.
Date last accuracy tested �,- ,� !�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy