2014_1007 C�IECK ONE:
IR.RIGATION �1/ DOMESTIC FIftELINE
BACKFI,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAN�OF PwS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �o�.� 1 � m�� � 1�Q P L.. Yl.
The bacl�flow prevmtion assembly detailed below has been tested aad maintaiaed as required by TNRCC
reguladons aad is cerdfied to be operating within acceptablc parameters.
TYPE OF ASSEMBLY
e , Reduced Pressure Principle C Pressure Vacui�Breaker
� Double Chxk Valve o Amnosphere Vacuum Breaker
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Manufact�uer � t7�' C� Siu _ `�
� f�=� r r�V�t���
Modei N�ber � �d-- Located At f`�G�� �v. ,;1 i�o rr� ��e-��/
,, i
Serial N�ber �� � � ��a�•
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check Valv�Assembly
ist Check 2ad Checi: Relief Valve Air.Inlet Check Valve
Inidal Test DGClosed Closed Tight Opened at Opened at osid
Tight Leal:ed ❑ Dsid _nsid
RP-_psid
I,�;� p Did not Opea o L,eal►ed �
�P�
and
Materials
Used
Test Aft,er DGClosed Closed Ti,ht o Opeaed at Opeaed at _�sid
Repair Tight o nsid osid
RP sid
The above is certifiod to be true.
Firm Name �; � �'f'�r-�lr.�-sr�E;r r)S rV,� �CeRified Testa �l �'C� �l�='r-� �"S ���
Firm Address ,'�;' `� -�. k Cat Testc No.�P����.��7C'f�Date !(� -�` �'-I
- -
_�=��f-�,v� 1 re.,Tx �����`�
Gauge # �� `r�, ( � � ,C Cj
llate last accuracy tested ;-,� -�- 1 �
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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