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2014_1213 C�IECK ONE: � IRRIGATION � DOMESTIC FIRELINE BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR? NAIv�OF PWS: CITY OF COPPELL PWS I.D. # � ,�, .,, ,. , _. � . LOCATION OF SERVICE: �' '��%��` �� '�� ,`t � .. _� � f� � �;` �' '� �. r.�' ' � ' � ��; i_: � �� , + The bacl�low preveation assembly detailed below has baa tested and mauatained as required b�, 'TNRCC reguladons aad is certified to be operating within accrptable paramcters. TYPE OF ASSEMBLY C � Reduced Pressvre Principle C Pmsure Vacuimm Breaker 9'' Double Check Valve o Atmosphere Vacuum Breaker Y, : Maaufact�aer �'�� I ��I �� Siu � �'/�� ;` Modei Ivt�ber -��) �� Located At ��l�` '• L� �� .;( � ; ',1 '. � � � Serial N�ber �L� r1� � �� 1' C I �! l.� t i�f REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Doubk Check v alv�Assembly ' __ _ . _.,- � .-- --- -- - lst Check 2nd Checl: Relief Valve Air Inlet Checic Valve Initial Test DGClosed Closed Ti�ht F Opened at Opened at osid Tight �,� �' Leal:ed o osid _�nsid ��'�I �" �d� Leal:ed s� o �, Did not Opea o Lesl:ed � �P� aad � ( Materials 4'�.� �, .'� � �.J �;%'�� (�,. Used � Test Aft,er DGClosed Closed Tight o Opmed at Opmed at _�sid Repair Tight o �sid nsid RP sid T'he above is catified to be true. 1 Firm Name I�►";��`, �,<� �'��- � `� i�-�`_: Certifiod Testc +�� U�c`� L�4�j� �' �. , ' .�, . -: � �- �, + ,;, 0 � � � -�� -_ Firm Addrrss �i� � ,�� S�,�1 i� �L��1 L- Cert Testc No. �:�1��i'��+�f� Date � �- �� 1�`-- 1 � Gauge # 1:��,;. t,, �:: -�L� �� I llate last accuracy tested �� ` �� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy