2015_0515 C�IECK ONE: �
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATTON OF SERVICE: � � ��� � `b � ��
The bacl�low prevmtion asscmbly decailed below has beea tested aad maiatained as required bv TNRCC
rc_sulations and is certified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
e uced Pressure Principle e Pressurc Vacu�Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Maaufactiaer � ��=CJ Siu �L�
Model Number �� Located At ��'.•t./� "�✓�
Serial Ntmmber �1 � � V�73��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check V alve Assembly
ist Check 2nd Checi: Relief Valve Air Inlet Check Valve
Ininal Test DC-Closed Closed Ti�ht � Opened at Opeaed at osid
Ti� � Leal:ed o �sid osid
RP-�psid
�� ❑ �� Did not Opea o Leai:ed �
�P�
aad
Materials
Usod
Test AR,er DC-Closed Closed Tight o Opeaed at Opmod at �sid
Repair Tight ❑ osid .�sid
RP sid
The above is c,ertified to be true.
901 a�Dr n CC[tified TGSta �� ��"`�'G�
Fi:m Na�e �-����'
Firm Address
Cert Testa No. �Q`�'>►S� Date ���s�S
(3auge # ���f�-� �f Z � �
llate last accuracy tested l�— Z �-L
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy