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2015_0112 C�iECK ONE: IRRIGATION DOMESTIC FIRELINE ✓ BACKF'LOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT NAN1E OF PWS: �I�Y��' �OPPELL PWS I.D. # �?51�11`1'l �/k�,�n ��L/�SS �ati.l� LOCATIOIv'OF SERVICE: a2 � � � T �� ' 73e baci�low prevearioa assembly detailed below has beea tested aad f11�+nt�ed as require� by TNRCC regulanons aad is carsifie�to bc operaung within acceptable param�ters. TYPE OF ASSEMBLY C Reduced Pressurc Driaciple ❑ Pressure Vacu�Breaker � Double Check Valve ❑ Atmosphere Vacuum Br�eaker W�"[T1 SiZe g'`i I Maaufacairer _� Modei Number �11`���L Locaud At �n ������ �L•'� �.,�,��-� �����. Serial Nimmbc QOI 7� � REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R ( Double Check Valve Assembly lst Check �nd Checi: Relief Valve Air Inlet Check Valve Ininal Test � DC-Closed { Closed Ti�t ❑ Opeaed at Opened at esid � '�i�t ❑ � I,cai:cd � Dsid osid ��;, RP-��sid ���`- �;� p Did not Open ❑ Leal:ed � Repairs � / � �fo2, '� �es�c�ks .t„�e�J• -� � ��fa��J � �nU�f1�7 �" /�S� c _ / � ` �� 2✓s � Tcs�� Materials � � �'�'j' `�' Used Test Af�s � DC-Ctascd a �losed Tight o Opened at Ogeaed at __Dsid Repair Tighi c � vsid osid � RP sid � The above is cu�fied to be ttuc. Firm Name l-A�'i�c-►�o.�ws�-z���. CertiSed Testc �.c�1'b��- � �► ►-e� Firm Address i?o,�;��s�'��-`Z�!-rs� ��i�j Cert. Testa No. o S Date ��= Gauge # b(p U;�7(,a„ llate Iast accuracy tested ` pC��•�� White - Customer's Copy Yeliow - City Copy Pink -Tester's Copy C�iECK ONE: IRRIGATION DOMESTIC FIRELINE �/ BACK�'LOW PatEVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: C17'Y QF COPPELL PWS i.I3. # �'(l7.(t�1 C��1,Z�ii (�uS c-f'CQ SS Y�i1�f LOCATiOIv'OF SERVICE: al.�S � CoI0r2t,Q:� -I�I rf' The bacleflow preveation �sscmbly derailed below has beea tested aad maint �*+ed as required by TNRCC reQulauons aad is cercifie�to bc ogerating within acr.eptablc paramcters. TYPE OF ASSEMBLY C Reduced Pn;ssure?rincip�c ❑ Pressure Vacu�Breaket '�-- Double Check 4 alve C Atmosphere Vacuum Brealcer Maaufacaaer ��� Siu '3/c�" Model Iv�ber ��7�/ Locaud At 1-„ Vt�.v��" /�4✓�r ��,,,�ur r>�C�,���,. Sczial N�mmbcr 7��`�� � �tEDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R ; Double C'heck Valve Assembly Ist Checic g 2ad Chec1. Relief Valve :dlir Inlet Check Valve Inival Test � DC-CFosc�. � CPosed Ti;ht a Opened at Opeaed at __�sid `��,� � Ti�ht ❑ 3 Lcal:�ci � �sid _osid � RP-opsid ; �' y,�;� ❑ Did noc Open o Lealced � L �� -�o �Coc K S �(/�'e ,�n �/o.� �� � �ov/�n�� /�/c��s �/a vc � �.�/ : and 3 ; I � 3i' / Mataials ; � Used ' Test Aftu # DC-Closed � �Posed Tight � Opeaed at Opeaed at osid Rtpair � Tight ❑ � �sid osid RP sid °; The above is catified to be�,ac. Firm Name r''-�Fi�t �o,�s�i� /s��`� Catifiod Testa�,(`�fln t n �'���v Firm Address �G'•�iX ns�8'rc�,� n 7��T5 Cat Testa No. �t�'oc�i r�SsS Date ��-��-I� (Gauge # - j)(o�770�7i� llate las� accuracy tested ��•3•�y White - �ustomer's Copy �'ellow - City Copy Pink-Tester's Copy