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2016_0215 (4) C�IECK ONE: �,. IRRIGATION DOMESTIC � FIRELINE BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT NAIv�OF PWS: CITY OF COPPELL PWS I.D. # _�; LOCATION OF SERVICE: �� , ��>��,� � �� t_. � o'� j�-�,�- .>.,_ ��. , � J -�� _ ��, � T3e bacl�low preveation assembly detailod below has beea tested aad maintained as required by TNRCC reguladons aad is cardfied to be operating withia acceptable paramcters. TYPE OF ASSEMBLY e Reduced Press�ure Principle C Pressure Vacu�Breaker '�''"� Double Check Valve 0 Am�osphere Vacuum Breaker Maaufactsaer '_ � ? +_ i Siu y'� �., , Model Iv�ber .�"`�:�� c_ E 3 Located At ��t ' ` �} - F� = �� _ �. r` /. �' �a �- Serial N�ber t. r '� �_� .; 4.., , REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly lst Check ?nd Checi: Relief Valve Air Inlet Checic Valve Inival Test DGClosed�%' �w Closed Ti;ht Opened at Opened at osid Ti,�ht Leal:ed ❑ nsid __osid � R.P-__psid ;. t I,eal;ed ❑ Did not Opea O Lealced o RePairs and Materials Usod Test After DC-Closed Closed Tight o Opened at Opeaed at �sid Repair Tighi o �Dsid nsid RP sid The above is cerdfied to be onu. _ .,__ , � . � � , � �� ;�� i , , i � Firm�Jame � ._ �<;; ..,• ��:� �.�� _,.,r� Certifiod Testc �� ,� �� ,_ ; �.�-' . .� -� � �„ , , � � __ . � Firm Address` � � ��' `��' �' � �_ � , '�t' Cert. Taster No. � �' �`� �' '� � Date 2 � � , �� ._ -� �;-. �;� > � Gauge # � ' � G�.:_, ti llate last accuracy tested ;`, � .� + �� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy __ , _ __ _. _ _ _ _ �