2014_0820 C�IECK ONE:
IRRIGATION � DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �-I �� ex4�T��
The bacl�low prevmtion asscmbly detailed below has beea tested aad main ain� � nq� bv TNRCC
regulations aad is cerdfied to be operating within ac�eptabla parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressure Vacuimm Breaker
� Double Check Valve o Amnosphere Vacuum Breaker
Manufactsaer t�E[�C c� Siu �`y
Modei Number ��C� Locaced At �_ _ S o i��= 1���� �, r
s«ia1 N�ber i��"c ���U Z
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
ist Check 2nd Checl: Relief Valve Air Inlet Check Valve
Inival Test DC-Closed Closed Ti�ht Opeaed at Opeaed at _nsid
Ti,r�t Leal:ed ❑ �sid _osid
R.P-�psid z,�
�;� ❑ Did not Opea o L,eal:ed O
��
aad
Materials
Used
Test After DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair TighL o �sid _._osid
RP sid
The above is certifiod to be true.
Firm Name Ki v' E�zS �fl� Ce�ttifiod Testa i�N���iv1/ SecrTT�
Firm Address C� Cert Testc No. t3 t�c.cc�r5�3 I Date �(-?c7--i�
j I l� "Z!a�Go
c�suge # 23 7 Z9�
Date last accuracy tested
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy