2015_0701 (3) C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREYENTION ASSEMBLY TEST AND MAINI'ENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATTON OF SERVICE: �I���,�t�A�!
T3e bacl.�tlow przveation asscmbly detailed below has baa itsted aad ma�nta�n� � nq� bv TNRCC
regulations aad is certified to be operating within acceptablc paramete�s.
TYPE OF ASSEMBLY
C Rtduced Pressvre Principle � Pressvre Vacut�Breaker
�4C. Double Chxk Valvc o Atmosphere Vacuum Breal:er
Maaufact�er �116��,1 N S Siu �/`� ,
Model N�ber �`1 V Jr� r.i� Locatod At r � � `�^ ��'115�ik% ��''�l'✓"�
Scrial N�ber �����a�. U X�-�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembiy
lst Check , 2nd Checl: ; ReIief Valve �lir Inlet Check Valve
Initial Test DGClosed Closed Ti�hht �4G Opeaed at Opened at _osid
Tidit � Leal:ed ❑ �sid osid
RP•_psid
�;� 0 Did not Opea � Leal:ed o
�P�
and
Materials
Usod
Test After DC-Closed Closed Tight o Opened at Opeaed at _�sid
Repair Tight o nsid _,_,osid
RP sid
T'he above is cati6ed to be true.
Firm Name����r�-C. �i�'�+���1►�� Cerdfiod Testa 1�_�llf1� �`�Y(,.+2
Firm Address�D� a� ; a { 'r�k, Cat Taster No.��Dl 64'�I Date ti I �U(�•.r
c�suge # � �i���t��.
Date last accuracy tested �,� �'�- �'�j
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy