2015_0202 (3) �G�✓ ��O co
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY F COPPELL
PWS I.D. # ,S ,� �
LOCATTON OF SERVICE: �O /t�� . �/7 D�CI
The baci�low prevmtion assembly detailed below has bxa tes�ed and maintain� � nq� bv TNRCC
regulations aad is cerdfied to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle e Pressure Vacuum Breaker
� Double Check V ve ❑ Atmosphere Vacuum Breaker
/ ' Z ��
Maaufacturer �n/ Size
Modal Number � Locaud At 4�
S����ba �ls,s-Gi3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubl�Chetk v alve Assembly
lst C3eck 2nd Checl: Relief Valve :�ir Inlet Check Valve
Inidal Test DGClosed Closed Ti�t Opened at Opened at osid
Tieht Leal:ed o nsid _osid
P0.5 s �--Psld
Leaiced ❑ � D id not Opea O L e a k e d o
�P�
and
Mataials
Used
Test After DC•Closcd Closcd Tight a Opened at Opeaod at __osid
Repair Tight ❑ nsid osid
RP sid
The above is catifiod w be true.
Firm Name CP-�-S� �`✓� �/'a�' Certified Tester r � �S
Firm Addrass �v.Q'� C�Y l.JII���:�'j Cert. Tater Na ' �13� Date 2`-2 " ��
!G S
Gauge # �����
llate last accuracy tested -'� '/ �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy