2015_0226 C�IECK ONE:
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IRRIGATION �"� DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REppRT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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LOCATIOIv'OF SERVICE: � �`; ,�
The bacl�-flow prevmtion assembly detailed below has beea tested and maintained as required by TNRCC
re_gulations and is cerdfied to be operating within acceptablc paramcters.
TYPE OF ASSEMBLY
C Reduced Pressvre Principle � Pressure Vacu�Brealcer
� Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufact�er � Siu
Modei Nimmber Locaud At � A'� - .`,
Scrial N�ber ' '
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check 2nd Chec�: Relief Valve Air Inlet Checic Valve
Inival Test DGClosed Closed Ti�t m' Opened at Opened at .nsid
� ', �� Ti�t ei�� Leal:ed 0 �sid _nsid
� ��:�' RP- � �" Dsid r
� Leal:ed o ���" �'-�� Did aot Opea o Leal:ed o �
�P�
aad
Macerials
Usod
Test After DC-Closed Closod Tight o pp�ned at Opeaod at _�sid
Rtpair Tight ❑ flsid _nsid
RP sid
The above is catified to be tive.
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Firm Name �.'r<< - �r , Certified Testa ,i,�= � t ��.,� !
Firm Address �� � %; 4�~ . '` `�:, � Cat Testa No. ��' I���`� Date ' �E�'���-
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Gauge # f I i `��)� .w�
llate last accuracy tested �j i�y! �'
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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