2016_0921 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: 1�J/'Ij�. — �-�(�� /l��AJD,sI'�,�'t�1 '��� ,�-�t�'
'Ibe bacl�low prevmtion asscmbly detailed below has beea tested aad ma�ntain� � nq� bv TNRCC
re_¢uladons and is certified to be operating within acceptable paramtters.
TYPE OF ASSEMHLY
f� Reduced Pressure Priaciple C Pressurc Vacuimm Breaker
❑ Double Check VaIvc � Atmosphere Vacuum Bresker
Manufact�acr �✓G � Siu �1_
Model Iv�ber
J��0 I �d�'�` i,o�c�a At G O� �Gr� K
Scriai N�ber �� o �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check 2nd Checl: ReIief Valve Air Inlet Checic Valve
Inival Test DC-Closed Closed Ti,�ht � t Opened at csid
Tight � Lcal:ed ❑ C���sid _nsid
RP-�,psid
Leal;ed o �' Z Did not Opea o I,eal►ed O
�P�
aad
Mataials
Used
Test After DC-Closed Closed T'ight o ppened at ppeaod at _�sid
Repair Tight � osid __osid
RP sid
The above is certified to be t:ve. �,��
� �-+`�� .
Firm Name ow Cerafi�d Testa � � l� ��',� .��
F;rm Address ��'Barton Circie Cat Tesca No. � Dace �2��
o,
Gg� # _C�i'll�19�
llate last accuracy tested �-J�-l6
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy