2016_0203 C�iECK ONE:
IRRIGATION DOMESTIC ✓ FIftELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATIOIv'OF SERVICE: g� ��'�� � 7� � !�i
The bacl�low preveation asscmbly decailai below has bxa t�stcd and maintaiaed as require� by TNRCC
reguladons and is cerdfied to be opera�ng within acceptable paramtters.
TYPE OF ASSEMBLY
C Reduced Press�urc Principlc ❑ Pressure Vacuimm Breaker
� Double Check Valve ❑ Amoosphere Vacuum Breal:er
Manufaciurer �G2.ri(� Siu � ��
Model Nt�ber L�a��7 N1 I Located At i� �- G � �
�� ���
Sezial Nimmber � 3 7Gj7�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACITfJM BREAI�R
Double Check v alve Assembly
lst C3eck 2ad Checi: Relief Valve Air Inlet Check Vaive
Initial Test DGClosed Z�� Closed Ti�t � Opened at Opened at nsid
Tisht � Leal:ed o nsid _nsid
RP-_,psid 2��
Leal;ed ❑ Did not Open o Leal:ed �
�P�
and
Materials
Used
Test Aftet DC-Closed Closed Tight o ppeaed at Opeaed at _�sid
Repair Tight o Dsid osid
R.P sid
The above is ' od to be
� ���1�.����'� ��� --�
Firm N Certified Testa rCr••l ���2. ��
Firm Address ��� ` �,..�,�t�a/t— Cat Tester No. � Date � - 3-l�
� ��� ���
Gauge # � �U f C��-C7�'f
llate last accuracy tested _ ,-- (S�-��
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy