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2014_1011 C�IECK ONE: IRRIGATION�_ DOMESTIC FIRELINE BACI{�'LOW PREVENTION ASSEMBLY TEST AND MAII�'TENANCE REPORT' NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: � 3S �I�M �ee ��QGZ The bacl�flow prevmtion assembly detailod below has beea tested aad ma�nta�n� � nq�� bv TNRCC re�ulanons aad is cerdfied to be operating within accep[able�parameters. TYPE OF ASSEMBLY C Reduced Pressvre Priaciple � Pressurc Vacuimm Breaker � Double Check Valve o Atmosphere Vacuum Breaker /�� Maaufactiaer �(�� Siu Modei Iv�ber a.SU Located At �Y�✓�cF- Si� lt�wl'l GZ.CV'dSS Serial Nimmber J��O�'(� � "`�►"' REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly lst Check 2nd Checl: Relief Valv� Air Inlet Check Valve Inidal�est DGClosed Closed Ti,Pht o Opeaed at Opened at osid `O-�(_�� Ti�i � Leal:ed � vsid _osid RP- ���Dsid ��}; ( Leal:ed o Dia noc Opea o Leal:ed o �� �.1�a�✓► �%cc� Materials �i�iVc.- ��/R- Used Test Aft,er DC-Closed Closed Tight �` Opeaed at Opeaed at __nsid Repair Tighi � osid _�sid �t,55 R.p z. 6 sid 2' � The above is cenified to be tiue. Fum Name ��' ��LG��C� Certifiod Testa gr�c� �Q.l�� Firm Address Pv bdx Z?D{I',� F�IrMe/I�Ifi�1�� Cert Tater No. (aD�Z 20 _Date 0� I�I y ?SaZ7 Gauge # 0 ?✓'O�D�,�Z llate last accuracy tested ������ White- Customer's Copy Yellow - City Copy Pink-Tester's Copy