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2015_0127 � 1� - 1 ti-/ _ �`7 ,�� C�IBCK ONE: IR.RIGATION �� DOMESTIC FIRELINE BACI4Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAIv�OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: �3 � I�-=►�.��. ��,r� ,.,�� The bacl�flow prevmtion assembly detailed below has beea tested aad ma�nra�n� � nq� bv TNRCC regulations aad is certified to be operating withia acceptable parameters. TYPE OF ASSEMBLY � Reduced Pressurc Principle ❑ Pressurc Vacu�Breaker � Double Check Valve o Atmosphere Vacuum Breal:er Maaufactzaer �� C � Siu � Modei Number �v Located At �-,� �e i � � r � �r � �� ,..rA Seriai N�ber >`� � 1��Z. ( `1 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly lst Check 2nd Checl: Relief Valve Air Inlet Check Vaive Inidal Test DGClosed3 �� losed Ti,pht Opeaed at Opeaed at _nsid Tight Leal:ed � �sid _�osid RP-_psid Z._� Leal:ed ❑ Did aot Opea o Leal:ed o �P� and Mataials Usod Test Aftet DC-Closed Closed Tight a pp�� ppeaed at �sid Repair Tight a _�sid __�osid RP sid The above is certified to be tnu. ,- . ` ..,� �f^ � -� Fitm Name��:1_��''' � t �', 'f ��`�';f �,l' I�s':ta,�'Cectifiod Tester # 't: � �,�,",r� :; � f.��_., r n �� Firm Addrass � /� � ''`�'s '>� ,' Cat Tester No. �>�' �-� =% 4x Date � `�"�� r`� � _, _� . , . �. , P �► �,'¢6t �t ; �� j ';� �".�; ) -� `�' Gauge # (`,%1 i ; t a <:j �,� llate lsst accuracy tested �' ",x f' /f-� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy