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C�IECK ONE:
IRRIGATION t/" DOMESTIC FIR.ELINE
BACKFLOW PREYENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAI�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��U ����-+- � �� �/
'Ibe bacicflow prevmtioa assembly decailed below has beea tested aad maintain� � nq� by TNRCC
re_gulanons and is certified to be opera�ng within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Priaciple � Pressure Vacut�Breaker
�'� Double Check Valve o Atmosphere Vacuum Breaker
,s � � /��
Maaufactiaer ��' Lr r _ Siu
Model Ivumber
�� Locaud At ��, � �%✓A
Serial N�ber
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubk Check Valve Assembly
lst Check 2ad Checi: Relief Valve Air Inl�t • Check Valve
Inival Test DGClosed Closed Tighi� Opeaed at Opened aL nsid
Tight eal:ed" ❑ Dsid osid
Rp- 2 3 vsid
i��, �� p Did not Opea o Leal:e� �
� ��t>
��
�
Materials
Used
Test After DC-Closed Closed Tight o ppened at Opmod at __�sid
Repair Tight o �sid osid
Rp sid
The above is cerrifiod to be true•
.�
Firm Name � �`-�',�- {" �;� ;_ �� Certifiod Testc �� , ���'�r^�"r a�_
l �
i:
Firm Ad�ress�'Y l-., l /�-__. ���.,�;T� �:. Cat Testc No.���'�``s•-`f,�k S� Date " � ' �'
L �
(�auge # ���L-'!s`���—
llate lsst accuracy tested ,���-/�f
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy