2015_0729 C�IECK ONE:
IRKIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
rr,�oF Pws: CITY OF COPPELL
PWS I.D. #
LOCATTON OF SERVICE: �`�-�� -
The bacl�low prevmtion asscmbly detaile� below has beea tested and maintained as required by TNRCC
regularions aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuimi Breaker
Double Check Valve ❑ Am�osphere Vacuum Breal:er
' Maaufact�uer ����, Siu �`� '
Model Number �C) Locat�d At �✓z-� ; �-��` ,�f
Serial N�ber ��L'%2 P �1
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CLJUM BREAI�R
Doublt Check v alve Assembly
lst Check 2 Checi: 'ef Valve Air Inlet Check Valve
Ininal Test DGClosed Closed Ti,Qht Opened at Opeaed at �nsid
Tight ,� � Leal:ed o �sid _flsid
�?-�r� t� RP-_psid � �
�;� ❑ Did not Opea o Leaked �
RePairs
and
Mataials
Usod
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at _nsid
Repair Tight o osid osid
RP sid
The above is cutified to be true.
��i ��;,
Firm Name #S,�x•�.f r�.c Catifiod Testa
�
Firm Addness !�� ��n �l����'1 �'w�,�:� Cert Tester No. `%` ?�`�'�'Date ��l��,5
(�auge # l v�l'c�>t�� E � �
Date last accuracy tested ��- i; I g
White- Customer's Copy Yellow - City Copy �Pink-Tester's Copy