2016_0215 (3) C�IECK ONE: __�._._.,.�,.�_.
IRItIGATION DOMESTIC ✓/( FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
rraiv�OF Pws: CITY OF COPPELL
PWS I.D. #
l +
LOCATION OF SERVICE: ������� �+ r v `�, f:�� f\J l� � c ��,,,, � I '�,.�„�..,
The bacl�low prevtation assembly detailod below has beea tested and maintained as required by TNRCC
regulanons aad is certified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
C Reduced Pressure Priaciple C Pressure Vacuimi Breaker
� Double Check Valve o Amiosphere Vacuum Breaker
t Z
Maaufactsaer t--��� S Siu
Model Number �-- �" `-'-� � M l Located At `��4 A � L, � i� ' ,;%'� r . V
� ..-, rP . �' v(' �-
Serial Nimmber
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double C3eck Valve Assembly
lst Check 2nd Chec]: Relief Valve Air Inlet Check Valve
Inival Test -Closed�� • � Closed Ti,�ht Opeaed at Opened at csid
Tight ❑ Leal:ed o �Dsid _osid
RP-_psid --z �
Leal;ed ❑ Did aot Opea o I,eaked o
�P�
aad
Materials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at �sid
Repair Tight ❑ osid __osid
RP sid
'Ibe above is cerdfied to be true.
Fiim Name �l�'��.� �� i�t�� �,�� {���-��Catified Tester �.+� ` �:�.. ���C x �i�Fr'�� � �
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Firm Address ��'b� '�f=`������ Cert Testa No. �'Ji�`��� Date � ' �` _ /(...
�'41 :1 ;'�J 1 i�,»i! ." 9 7 t,�.
�. . . ��7��- �`}I��i ��
(�auge # ��� � ������
Date ]ast accuracy tested � ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy
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