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2015_0220 C�iECK ONE: IRRIGATION X _ DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT N�ME oF Pws: CITY OF COPPELL PWS I.D. # ' LOCATION OF SERVICE: 3�i'� � � -�� The bacicflow przvcation asscmbly detailed bclow has beea tested and ma�nta�n� � nq�� bv TNRCC regulanons and is certified to bc operating within acceptable paramcters. TYPE OF ASSEMBLY � Reducad Pressure Principlc C Pressvre Vacuimm Breaker Doublc Chxk Valve � Atmospherc Vacuum Breaker Maaufactiaer �� ' Siu �� Modei Iv�ber Y� y� Locaud At �-�-� ' Serial N�ber _�� 1�7 ! � REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE VACULTM BREAI�R Double Check Valve Assembly lst C3eck 2nd Checl: Relief Valve Air Inlet Checic Valve Inidal Test DGClosed � •�� Closed Ti;ht ed at Opeaed at esid Tight � Leal:ed �' nsid osid RP-_psid L,�;� p Did not Opea o I,eal:ed ❑ �P� aad Mataials Usod Test ARet DC•Closed Closed Tight o Opeaed at Opmed at __�sid Repair Tight o �sid osid RP sid The above is c�Rified to be true. ; , , Firm Name e... . Cectified Testa �`�� `� ��'��` '`` Firm Address � ,n�'1 I� a��-- � `��-Cert. TcstcNa �--�� v Date Z - Z a -� � � � �H � �,r,� 7 � �,�� (3auge # _�' � D/(�� C'`'�j llate last accuracy tested ! - z 7- f j White- Customer's Copy Yellow - City Copy Pink-Tester's Copy . _ _ _