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2014_1203 C�iBCK ONE: IRRIGATION v� DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # , LOCATION OF SERVICE: �c� � �� E' F�N"f' ? �i�. The bac�.�flow preveation asscmbly detailed below has beea t�sted aad maiatained as required by TNRCC reguladons aad is ctrtified to be operating withia accrptable paramtters. TYPE OF ASSEMBLY �; Reduced Pressure Principle C Pressurc Vacu�Breaker � Double Chxk Valve � Amiosphere Vacuum Breaker �"��C� C� Siu ��! Manufactsaer `'' Modei Iv�ber T� '4`)a Located At �``��.�'F' r' ��r� l��'�',E-� �' ��- t�t;'.�-'� f `:`, � Serial Nimmber � � �J��1 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Cherk v alve Assembly lst Check 2nd Checi: Relief Valve Air Inlet Checic Valve Ininal Test DGClosed 'Closed Tight Opened at Opeaed at nsid Ti�t Leal:ed � �sid _osid RP-_psid �;� ❑ Did not Opm o Leal;e� o RePairs aad Mataials Used Test ARer DGClosed Closod Tight o Opeaed at Opeaod at �nsid Rtpair Tight ❑ �sid _nsid RP sid The above is catified to be true. Firm Name �i_ _i.�i�� +'�f Certifiod Tata ��E V�'r; ��ji_'S�-Z,r`� �,,�. ' .�.� �� , � �� Firm Address � Cert. Testc No. ate 1�-— '�— �.�.�:,�) j_.��!i � �' �h'._7�,,�- .�;�� ; .:� .L.-=- �Ig�e f / .F a�� r. ��f!\/y ��{��/�_:. � llate last accuracy tested �.,� -�) -�,�� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy _ _ _