2015_0202 (4) �3L � 7 z 8"�
C�IECK ONE:
IRRIGATION DOMESTIC FIRELINE�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY F COPPELL
PWS I.D. # �/, ��• � ��
LOCATTON OF SERVICE: /D �T �� . D
The bacl�low preveation assembly detailed below has been tested aad maintained as required by TNRCC
reguladons aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacu�Breaker
� Double Chcck VaIv ❑ Amiosphere Vacuum Breaker
//
Maaufacturer Siu
Model Number ��� Locatad At �e �� � t� �� �
��. �� G.��r� �-SC��
Serial N�bcr _T
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Double Cherk v alve Assembly
lst C3eck 2nd Checl: Reiief Valve 4ir Inlet Check Valve
Initial Test DC-Closed Closed Ti;ht Opeaed at Opened at nsid
Tight �7— Leal:ed ❑ nsid _osid
Q0. y y �-_Ps�d
Leal:ed a '° Dia noc opea o Leai:ed n
�P�
and
Materials
Used
Test Ai�s DC-Closed Closed Tight o Opeaed at Opeaed at _nsid
Repair Tight ❑ �sid _�osid
RP sid
The above is catifiod to be true.
Firm Name �. �,� I�rQ: Certifiod Testa r �- �-5
Firm Address � /4� �,T"i Cert. Tester No. � .� Date � � — ��
,� �s��y
Gauge # c���6�
llate last accuracy tested �- -
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy