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2016_0215 (2) C�iECK ONE: IRRIGATION DOMESTIC �� FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT N�ME OF PwS: CITY OF COPPELL PWS I.D.# LOCATION OF SERVICE: ` - � � 4 ' � , , v_ ,.• �?,.:, ✓ s� • t. ..� ,�,v j. r' H • j`�.,r �` � � �� The bacl�low prevmtion assembly detailed below has beea t�ested aad mainta�n� � nq� bv TNRCC regularions aad is cerdfied to be operatiag within acceptable parameters. TYPE OF ASSEMBLY e Reduced Pressure Principle ❑ Pressure Vacu�Breaker 3-'"" Double Chcck Valvc o Amoosphere Vacuum Breaker Maaufactsaer �..� < � r� .� � Siu ' 7 , , � Model Number .-� `�� '� '�� � Locatad At v'=� - ° � ' "�, ' 1� -� - " Serial N�ber ���;� _ � -, �, � �� . . R�"�,.� _. � ; ,,. ,. 1 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Cbeck Valve Assembly lst Check 2nd Checl: Relief Valve Air Inlet Check Valve Inival Test DC-Closed� � Closed Ti;ht Opened at Opened at csid Tight Leal:ed ❑ _�sid osid RP-__psid c '�=� Leal:ed o Did not Opea o Leal:ed o �Paire aad Materials Usod Test After DC-Closed Closed Tight o ppeaed at Opeaed at __nsid Repair Tight o �sid _csid RP sid The above is cuafied to be t�ue. .,, , , , e Firm Name ° � v`« �; �J r�r:; ' � '-� Certifiad Testa f '`'�`- ,�>` ,, _�'�' , -- -R _ , > � � �. : _ _ � , _ - , Firm Address'` �`� ,��" '" �_ �� "'� ` l�� Cert. Tester No. �� ' � "� �` �'�' Date ' � _ �� -�'`�� --7 �' s 'y �; Gauge # t_.:.; � r ( � =7 ,, �llate last accuracy tested �:� � ���`� � �ti White- Customer's Copy Yellow - City Copy Pink-Tester's Copy _ _