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2015_0211 C�IECK ONE: � IR.RIGATION DOMESTIC FIRELINE BACI�LOW PREVENTTON ASSEMBLY TEST AND MAINTENANCE REPORT NAN�OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: _�sJ �" -'�• ��`�J.a�w�. �'� - �� ,�rC":�` The bacl�low preveation asscmbly detailed below has bxa tested aad maintained as required by TNRCC re�¢ulations aad is cerdfied to be opera�ng within acccptable paramtters. TYPE OF ASSEMBLY C Raiuced Pressure Principle C Pressure Vacutmm Breaker � Double Check Valve � Atmosphere Vacuum Breaker Manufact�er ��/�% �� _ Siu �J�� ` i � Modei N�ber � '�;��r� Located At � G%y ��%'r�%`i/�'c- --,�;+� , Scrial Ntmmber �--�� d � �''�'' � ;/�" ` �'�---��,�" J REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembiy lst Check 2ad Checl: Relief Vatve Air Inlet Check Valve Inirial Test DGClosed '�� Closed Ti;ht ' Opeaed at Opened at osid Tidit � Leal:cd o nsid �osid R.P-_,psid �;� o Did not Open O Leal:ed � �P� and Mataials Used Test AR,er DGClosed Closed Tight o Opeaed at Opmed at �sid Repair Tight ❑ nsid osid RP sid The above is cerdfied to be orue. � � ' � '�� .,.. � ��, Y s� '� Firm Name ` ' i�c��','� _ :;� �L� Certifiod Tester �� ' 0�� '�� /C �4Jr� � ,� (. �� Firm Addr�ss =°��%�:��- �` .[,-� ='-��""-f'�z Cat Testa No. ? �- ''� Date�� , '' � _ (r: ; ��;��z ��,�.- .i��, ; ,;t==. ' .��.-, � G Gauge # �� t%T�'�7-�=� llate last accuracy tested � � �� 1�-' White- Customer's Copy Yellow - City Copy Pink-Tester's Copy