2015_0320 C�IECK ONE:
LRRIGATION�_ DOMESTIC FIRELINE
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv OF SERVICE: LI�� �1'; ..�(��f�I�.0
The bacl►�tlow prevmtion asscmbly detailed below has beea tested 3ad ma�nt�ed as required by TNRCC
rcgulanons and is certified to be operadng within acr.cptablc parameters.
TYPE OF ASSEMBLY
C Reduced Pressurc Principlc � Pressure Vacu�Breaker
�, Doublc Chcck VaIve a Atmosphcre Vacuum Breal:er
/ /��
Manufacturer �f7G� Siu
Modei Nt�ber o�� Locaud At �v/P��
Serial Nimmber t7�,�7��.�CY
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valve :�ir Inlet Check Valve
Iniaal Test DC-Closed�� `f Closed Ti�ht /� Opened at Opened at osid
Tidit � Lcal:ed ❑ nsid nsid
R.P-_psid
�;� ❑ �. . �, Did not Opea o Leal:ed ❑
�P�
and
Materials
Used
Test After DGClosed Closed Tight o Opened at Opeaed at _nsid
Repair Tight o �sid osid
RP sid
The above is catified to be true.
Firm Name Ol Accuracy�ckflow C��T� `�/�M(�� ����,�f�
arton Circte ��
g�pd� Frisco, TX 75035 Cat Tcster No. Date .� �Z S
972-699-7156
Gauge # ����?.�. �
llate last accuracy tested /r K'/�
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy