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2015_1013 C�iECK ONE: IRRIGATION V DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # ° t.:� r4 LOCATION OF SERVICE: ��: � � �--�� '"� � �`'��' ✓i r.-- The bacl�low preveation asscmbly detaile� below has bxn tested aad ma�nta�n� � nq� bv 'INRCC ' reguladons and is certified to be operating within accrptable parameters. TYPE OF ASSEMBLY � Reduced Pressvre Principle ❑ Pressure Vacuimm Breaker �'� Double Chcck Valve ❑ Atmospherc Vacuum Breaker Maaufactsaer `-e.+�{ �': /; "< Siu i/��-d � Model Number '} �-�' Located At r,, �c:;�� P :� �f �i Serial N�ber �%� �:�._�; � �, �i--�t�— REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly 1st Check 2nd Chec�: Relief V,alve Air Inlet Check Valve Ininal Test DC-Closed Closed Ti;ht o� Dpened at Opened at nsid - Tight v; J "Leal:ed o �sid _osid RP-_psid �;� c � LeaI;ed ❑ Did noc Opea � Leal:ed J �P� aad Materials Usod Test After DC-Closed Closad Tight o ppened at ppeaed at _s sid Rapair Tight � osid osid R.P sid The above is certified to be true. ,�-- ; ; Firm Name `� . ��"r'`."i° CQti1fiCd TGSLC! � �%' e' �'�- U � �' �'f� �"L'-; , � _.. � , , , - .C� s-��. �� .; v��;�,.: ...-. Firm Address �� r�r'.��'',�-=� �� ''Cert. Tesier No. �"� `� '��r 1 Date �'�� '�,; .� (3auge #c'; �'-�,`�.t l G''; �� Date last accuracy tested ;�� .� r`�- � White- Customer's Copy Yellow - City Copy Pink-Tester's Copy � _