2014_1212 C�IECK ONE:
IRRIGATION DOMESTIC FIR.ELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
N�OF Pws: CITY OF COPPELL
PWS I.D.#
.—
LOCATION OF SERVICE: ��� �e�'f�'r e
The bacl�low prevmtion asscmbly detaile� below has beea tested aad maiatained as required bv TNRCC
re_sulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C / Raiuced Pressure Principle e Pmsurc Vacu�Breaker
�f Double Chcck Valve ❑ Atmosphere Vacuum Breaker
Maaufactsaer ���c� Siu 3l�r' �
Model Number � Locaud At ��� `'��;�
Serial N�mmber ���G�`'°`'
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM$REAI�R
Double Check v alv�Assembly
lst Checic 2nd Chec�: 'ef Valv� Air Inlet Check Valve ,
Inival Test DGClosed losed Ti.ght Opeaed at Opeaed at csid
Tight ! `� Leal:ed 0 nsid _osid
��..�� i�( RP--Fsid z. t
I,�;� ❑ Did not Opea o Leal:ed �
RePairs
aad �
Materials
Used
Test After DGClosed Closod Tight o Opened at Opeaed at ___flsid
Repair Tight ❑ osid __nsid _
RP sid
The above is certified to be true.
Firm Name 1���r��t�,��� Cettifiod Testa lc•� ,l>��✓r/'
�
Firm Address ���x ,ac��gS �'���,%r.,.�. ��' Cat Testa No. ��f.t',Cl��`l Date ��"_�
_,.
Gauge # (� l3Z565
llate last accuracy tested - - �
White- Customer's Copy Yellow -,City Copy Pink-Tester's Copy