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2015_0820 C�IECK ONE: IRAIGATION DOMESTIC V FIRELINE BACKFLOW PREVENTION ASSEII�IBLY TEST AND MAIIVT'ENANCE REPOR? NAIv�OF PwS: CITY OF �'OPPELL PWS I.D. # ��, ,;`.�� ; R�;+�, , LOCATTONOFSERVTC�: `�f 5� �o,�� ,`,��.�,y �� ={�z� �c��R "r'`-��`I`� The bacl�Iow prcvcation asscmbly detailed bclow has been testcd aad maintained as required bv TNRCC rcgulations and is ccrtified to be agcrating wit}�i.n acceptablo pazamctcrs. 'iYPE OF ASSEMBLY C Reducad Pressure Priacit�Ic e Pressure Vacutmi Breaker � Doublc Ch�ck Valve � A�nospherc Vacuum Breakcr Maaufacn.ffcr �A'CC 5 S ize a,1 ModelNt�ber �1 �1 LocatedAt Wf�� o�- t�:�e5� ,� s«��N�b� 1 q��l� REDUCED PRESSURE PRINC�LE ASSEh�LY PRESSURE vACUUM BREAI�R Double Check v alve Assembly lst Checl: 2ad Checl: Relief Vatve Air Inlet Check Valve Inidal Test DC-Closcd Closod Ti�t Ogencd at Opaaed at osid Ti�t � ►� d L.eal:ed o Dsid osid ��-�5 �-�.Psid �,� � ❑ Did not Opea o Leal:ed � �Pa+rc and Matcrials Used Test Aftet DC-Closed Closed Tight o Opened at Opme�at __�s�d Repair Tight ❑ �sid nsid RP sid Tho above is certified to be tzue, �� 1�1,ti t:;, ;1�� l�;�a��.' Firm Nam,e �C��,�� ``�_` �. Certified Testc Firm Address�' �'�` L �'`�� C.7 � Cert. Testa No.\�i��'L`!�( �� ` I D� �`� .�� ;=��l �.��> T a� `I �� / Gauge # � �� 0 � �C-� llate last accuracy tested 7/� �� C�IECK ONE: IRRIGATION DOMESTIG FIRELINE ✓ BACI�Z.OW PREVE�V'TION ASSEMBLY TEST AND MAINTENANCE REPORT' NAN�OF PWS: CITY�F COPPELL PWS I.D.# '�-,'�:'�'*= �� ;l'�`%, ,, LOCATION QF Sr�VIC�°� `�1 �� ,�1��- C�,�,,-��i:;y 1_�� '�'j".`t�,.� � C,��``��. ��,`�� The bacl�low prcvmnon asscmbly detail�d bcIaw has bem ttsted aad ma�nt�ned as required by TNRCC rcgulations aad is ccmfial to be operanng withan acceptablc paramcters. iYPE OF ASSEMBLY c Reduced Pressurc Pri�ci�lc C Pressur�Vacuum Breakcr � Doublc Chc,�k V�Ivc � Amnosphere Vacuum Brcaker Manufacturcr �RT`� Siu ��N`, Model Numbcr �1 M3 Located At W�.5� o� WEs-� '[}C�� ScriaiN�ber 2�O��q REY�UCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assem�ly lst Cbec1; 2nd Checl: Relief Valve Air Inlet Check Valve Ini�al Test DC-Closcd Closed Ti�ht Opeaed at Opened at � osid Ti�t �- �� Leal:cd ❑ �sid osid Q.�S RP-�,psid �,� � ❑ Did not Opea O Leal:ed ❑ �P� and Materials Used Tast After DC-Cioscd Closcd Tight o Opeaed at Ogea�ac �sid Repair Tight ❑ flsid osid � RP sid .._�- ,,---� �.:. The above is cerhfied to be true. `J.✓ �" . : �--- Firm Name �c�'r"�:�� \'-� "t. Catified Testc ��Z�,,� I ;1�f C(., ��I�;��.,�' :: �,C � ��.�� `�� Cert T�No.��`"�`�� Date �/�C' F' Fi:m Address��.] at L�� .1 ,��-,; T� �7 �.�� 1 c_� Gauge # ��' � � `� llate last accuracy tested �� C /� ) �� C�IECK ONE: � IRRIGATION ^ DOMESTIC� FIftELINE G, BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # ��1�� Q��S LOCATION OF SERVICE: �5�� C O�S� S�.�'�Z �A� ��j� C�p��1 ��C�� The bacl�low prevmtion asscmbly detailed below has bxa tested and ma�nta�n� as required by TNRCC reguladons and is certified to bc operating within acceptablc paramcters. TYPE OF ASSEMBLY C Reduc�Pressurc Principle C Pressure Vacu�Breaktr .^/ Double Chcck Valve o Amzosphere Vacuum Breal:er Maaufact�uer �n',A�S Siu 1 � `5 � Model N�ber O�l��M.�- Locaud At �Es� nC W�`>� �� `�`�'. Serial Nimmber �� -��Q REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAI�R Doubie Check Valve Assembly lst Check 2nd Checi: Relief Valve Air Inlet Checic Valve Inival Test DGClosed Closed Tight d Opened at Opened at vsid Ti�t � �� Leal:ed o nsid osid � �� RP-_psid � 1 �- Leal:ed ❑ `D Did not Opea o Leal:ed � �Pa�re and Matet�ials Used Test Aft�x DGCloscd Closed Tight o Opmed at Openod at nsid Repair Tight o �sid osid RP sid ... The above is certified to be true. �%'�..,---' Firm Name �� C�: CeraSed Tessca (Y��Ch��•F � �� Firm Address �7 � C n.f c S� Ccrt. Tester No.� �� I Date �l�� A\ �� T� � S�� 7 cguge # �� 1 � `�� llate last accuracy tested �� Q /I 5 White - Customer's Copy Yellow - City Copy Pink-Tester's Copy