2015_0220 (2) C�IECK ONE:
IRRIGATION�_ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATIOIv'OF SERVICE: '��f 1�—��2�1C� L.,�l�._i�'
The bacl�low prevmtion assembly detailed below has baa tested aad maiatained as required by TNRCC
regulauons and is certified to bc operating within acceptablc paramcters.
TYPE OF ASSEMBLY
❑ Reduced Pressurc Principle C Pressure Vacu�Breaker
� Double Chcck Valve ❑ Amiosphere Vacuum Breal:er
Maaufacturer �'� r�� S� ��J '�
Mode1 Number E�� Located At �Z��� ��vz-�..
serial Nimmber ��, �b L�' 3 1 �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checi: Relief Valve Air Inlet Checic Valve
2,
Inidal Test DGClosed ��� Closed Ti;ht � Opeaed at Opened at esid
Tight � Leal:ed o nsid nsid
R.P-_psid
�;� ❑ Did not Opm o 1,eaked �
RePairs
and
Materials
Used
Test Aft,er DC-Closed Closed Tight o Opeaed at Opeaad at �sid
Repair Tight a �sid _,_nsid
R.P sid
The above is certified to be true.
Firm Name �,�1 I��r.) ����L�a�:,� ��� Certified Tester I`'��.� C- �I ��w z t5 �t
Firm Address ��� 7 �r� ���I�� �"�-- Cat Testa No.l�P �-`a 3�' Date Z - z o. � �
`>�n� T��v �_� 1�z�'S-
(=auge # !I o d r�� zl�r'�
llate last accuracy tested ( - �. � - �5
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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