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2015_0119 C�IECK ONE: IR.RIGATION�_ DOMESTIC FIftELINS BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAIv�OF PWS: CITY OF COPPELL PWS I.D. # L�OCATION OF SERVICE: �/� L</�� (��= ;�1� r. �I� ��S C_�. The bacl��low preveation assembly detailed below has beea tested aad maintain� � nq�� CC reguladons and is cercified to be operating withia acceptablc parameters. TYPE OF ASSEMHLY e Reduced Pressure Principle � Pressure Vacu�Breaker `� Double Check Valve ❑ Amiosphere Vacuum Breaker Maaufactiaer /G �� Siu � " Model Number ��' Located At i�� ' f�'�' S�c� � ,/.:t ��-1 f��/r� ;;�,,, //L- Serial N�ber 3'4 ��" REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check v alve Assembly lst Check 2nd Checl: Relief Valve Air Inlet Checic Valve Inival Test DGClosed Closed Ti,pht �$` Opened at Opened at nsid �_��.,r 5 Tight � Leal:ed ❑ �sid __osid R.P- -'��psid 1, � �>�.5� I,eal;ed o I}id not Opea o Leal:ed � �P� and Materials Uscd Test After DC-Closed Closed Tight o ppeaed at ppeaed at _�sid Repair Tighi o osid __,osid R.P sid The above is certified w be true. Firm Name �N �''r�t 1�:{��`�r,T Certifiod Testa ��u C� { ��r r� Firm Address U�u X� 2?�ll 5' Cert. Tester No. ��t�:rZ 7 Z U �� --_ ��_�y ��(/i'ri>> ��!uv�k , �) }(� ,h(�l� � Gauge # � �i`�U��Z llate last accuracy tested 7 "/��/�` White- Customer's Copy Yellow - City Copy Pink-Tester's Copy _ i _ _