2014_0515 m. ..,,. �..: ��, �, , .., . . . � , . _ . . ,. _.
C�iECK �NE:
IRRIGATION t/ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: /��1� ,/�����
The bacl�low preveation assembly detaile� below has beea tested and maiatained as required bv TNItCC
re�uladons aad is cerdfied to be operating withia acceptable paramtters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle � Pressure Vacuimm Breaker
5-/y Doublc Chcck Valve o Amiosphere Vacuum BrealcGr
r � � If �
Maaufact�uer �r l, , Siu
, � ;�
Modei Ivumber �'/�/ Located At Ty�r, ;/r` � �� „�`��
Scrial Nimmber v-�' �'�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R
Double Check Ya1v�Assembly
lst Check 2nd Chec1: Relief Valve :�ir Inl�t Check Va1ve
Inival Test DGClosed losed Tia t � ed at Opened at esid
Tisht Leal:ed o nsid osid
RP•�-�psid
�� ❑ Did aot Open o Leaked �
RePairs
and
Mataials
Used
Test After DGClosed Closed Tight o Opeaed at Opeaad at �sid
Repair Tight ❑ �sid osid
R.p sid
'Il�e above is certified to be true.
Firm Name l� �'�r c,�,/r� _t�;s. ��_ Certified Testa � �"
Firm Address �'� �--�- 1/.�- f�'�,��.r �1l Cert.Teste No��U�f;;,�� Date ` 1 �
T Y,_�_� ;_-
✓ L,
Gauge # �i/�;/; �� k-
llate last accuracy tested 1 '".-' S-/Y
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy