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2014_0818 C�IECK ONE: IRRIGATION � DOMESTIC FIRELINE BACT�'LOW PREVENTION ASS�EMBLY TEST AND MAINTENANCE REPOR? �. NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: �Ja) �,�.� v, / The bacl�low przvmtion asscmbly detailod below has bxa tested 3ad ma�ntain� � nq�� bv TNRCC reguladons and is certified to bc operating within acceptable paramcters. TYPE OF ASSEMBLY e Reduced Pressure Priaciple ❑ Pressure Vacu�Breaker �� Double Chcck Valve ❑ Atmosphere Vacuum Breaker �� i Maaufacturer /�� i, Siu __.:-__ . l 'Modei Iv�ber 1'� Located At �c �� %.�d �7��` Scrial Nimmber '�Y7 ?�h 1'�0 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly lst Check 2nd Checl: Relief�alve Air Inlet Check Valve Iaitial Test DGClosed Closed Ti;h�t � ed at Opened at �Dsid Tieht rLeal:ed ❑ vsid nsid ,` RP-�psid ; �. � �,�� I,eal;ed o Did not Opea o Leal:ed ❑ RtPairs _. and Mataials � Used Test AR,er DGClosed Closed Tight o Opened at Opmed at __�sid Repair Tight ❑ csid nsid RP sid The above is cudfiod to be true. �Firm Name �f ��_� �,r� i.-i. �� ; Certified Testa �� '"��:��-�-�-�.� G' : Firm Address �v�� t•�- / 1._ _ � �,.-.,�; Cat Tester No.��-t��`�� Date � �`� I � C� '� (iauge � �1,/G%(i ,/, �` llate last accuracy tested ��~ �r-J� White-Customer's C�opy Yellow -City Copy Pink-Tester's Copy