2014_0716 C�IECK ONE:
IRRIGATION_� DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
rra►iv�OF Pws: CITY OF COPPELL
PWS I.D. #
LOCATTON OF SERVICE: ��'v �. �'a� �' Z �
The bacl�low preveation assembly detailed below has beea tested aad ma�ntain� � nq�� bv TNRCC
reguladons and is cercified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Priaciple e Pressure Vacu�Breaker
,2' Double Check Valvc ❑ Am�osphere Vacuum Breakec
/
Manufact�aer -��.b c�v Siu � �z
Modei Ivumber �`�� Locatad At ��r�� � �,� /Lc.e �,�
Scrial Nimmber T7 3� �� 2
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check �nd CLecl: Relief Valve Air ldet Checic Valve
Inival Test D - osed�-� Closed Ti,,P.h Opened at Opeaed at nsid
❑ Leal:ed o Dsid nsid
RP-_psid
�;� o Did not Opea O Leal►ed �
�P�
aad
Materials
Usod
Test Aft,er DC-Closed Closod?ight o Opeaed at Opeaod at _nsid
Repair Tight ❑ �sid _osid
R.P sid
The above is certified to be true.
Firm Name �I �/Y1��ri��h �cr���IA�v' Certifiod Tester �7`i n �
Firm Address ���3 ��i G�Gl./�_/�l�� Cert Testc No. �0� $S Date� � — z
cg� � �j� Z Z 2 ��
Date last accuracy tested - � �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy