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2015_0112 C�IECK ONE: IRRIGA�'ION DOMESTIC FIRELINE v BACI�'LOW PREdENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REPORT NAIviE OF PWS: �'1�'Y OF COPPELL PWS I.I�. # � �Gl G��C �Piit� LOCATION aF SERVICE: o73 � � � - ��1 q Thc bacl�low greveatioa asscmbly deuailed below h� bxa tested and maiataiaed as requir�d by TNRCC rePuianons aad is ccrdfied�be op�aating within ac�eptable parameters. '�YPE OF ASSEMBLY � Rcducec�Pr�ssure�rizicip&c ❑ Pressure Vacu�Breaker � �ouble Chx�:VaIve G Amnosphere Vacuum Breaker Maaufact�er Q,�S�-�I �-e-ex3 Size 3/�'� Modei N�bcr '�AC� Located At �►-� 1/o.0 I� �t•S�^�� c��?rz;�- Scrial ltiamsb� �'1��.o'�Ot7 � �tEDUCE� PRESS€JItE PRIN�LE ASSEMBLY PRESSURE V�CULTM BREAI�R " Double Z:hetk Valve Assembly lst ChecT� b ?nd Checl: Relief Vatve Air Inlet Check Valve Initial Test � DC-Closed � �Iosed Ti�t ❑ Opened at Opened at nsid � Ti�t �� Lcal:ed ❑ �sid �sid �j � RP-_,psid ; � � Lcal:ed o f � Did not Opea ❑ Leal:ed o f ,� e� �a� -�cl �� ! C���c�r'�- 1�.���-�-� �c"' o'-� �`1p,ss �""`��' Materials � (le.es� � '��F '�-� �`��� �`^ Used � " Test After � DC-Closed s �losed Tight � Opmed ai Ogmed at __nsid Repair Tight � � flsid Dsid � RP sid f The above as cu�fioci ua be�sae. Fum Name /-�J�n- �L��fi� itsh� Certifiod Tata [ i��.x i�%"/(>y� Firm Address��.�x 1�SL(g �,�T;v�'1�11``� Cat Testc No. �b S� Date t-t�--1�,' Gauge # �(00—[��(P llate last accuracy tested �" White - Customer's Copy Yellow - City Copy Pink-Tester's Copy C�IECK �NE: IRRIGATION D�MESTIC FIRELINfi " BAC�'�.OW PRE��'i'ION ASSEMBLY TEST AND MAIN'TENANCE REPORT NAME OF P�VS: �'I7'Y C�� COPPELL PWS I.D. # �� �G C,�%rt,t-�it --� LOCATION OF SERVICE: Z3 - � '15a l S The bacl.�flow prevea�o� asscm'�ly desailed below has beea tested aad t1],ainfain� � nq� bv TNRCC regulaaons and is cer�ifie�ta be operating within ac�eptable parameters. '�Y?E OF ASSEMBLY C Reduced�ressure�'rincipie C Pressure Vacu�Breaker ('� J�u�Ie Chxx V a�ve G A�osphere Vacuum Breal:er ��C Maaufacturer ��P,c.n Siu Modei 2v�bes �,)�C��- Locaud As .ir� �/o��' �'�- �� J�C�e o-�-����� scrial N�mmber �-1 � 0 1�� < RE�'�TCEI3 PRESSi,� PRIN�LE ASSEMBLY PRESSURE VACULJM BREAKER � �ouble�hezlc d aive Assembly lst Check 2ad Checl: Reiief�alve Air Inlet Check Valve Ininal Tes2 � DC-Closaa € �tosed?'i;ht t�,' Opeaed at Opened at osid � �'I�S �,'� Lrzg;ed � ; nsid _�sid �`� � �-�sac� � C� � � � I,�;� �, � �� Did not Opm o Lealced � Repairs s and £ � � MataiaL� " " � LiRl i Tcst After � DC-Clased $ �Iosed Tight � Opened at Opeaed at nsid Repair Tight � � �sid osid RP sid � 'I'he above is certified ta;��*,ae. f irm Name ��1���e��,�rv�i-`►� _ �ertified Testa � ;�.��,s1 i!�%UG-��^ Firm Address� ,��eTx 7�C� Cert. Testa No. S3 �Date �- t-c�— �5 Gauge # b(�U�dS�� llate las� �c�uracy teste� - White - �ustorner°s Cop� �'eliow - City Copy Pink -Tester's Copy