2016_0930 C�IECK �NE:
IRRIGATION�_ DOMESTIC FIRELINB
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAI�OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �,�,I 1:=,��1� �i��(����i
The baclflow preveation assembly detailed below has beea tasted and maiatained as nquired bv TNRCC
regulations aad is certified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacutmm Breaker
�l Double Check VaIve o Atmosphere Vacuum Breaker
���
Manufacuaer �✓�� � Siu
Modei Number C,�71�1� ��,� Locaud At �f ��'���
Scrial Nimmber 4l'T� �`� I
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubie Check v alve Assembly
lst Check 2nd Checl: Relief Valve Air Inlet Check Valve
Ininal Test DGClosed �.� Closed Ti;ht � Opeaed at Opened at nsid
Tight �1. Leal:ed o nsid _osid
RP-__psid
Leal;ed � ��� Did not Opea o I,eaked o
�P�
aad
Materials
Used
Test ARer DC-Closed Closed Tight o Opened at ppme�at _�sid
Repair Tight � _csid �,osid
R.P sid
The above is ceRifiod to be true. ,� ,
; ��[�' _
Fiim Name Certifiod Tester
- q,
Firmqddress �9'90'Barton Circle Cerc. TestcNo.� Dace "��- �
rtsco, TX 75035
Gauge # ��JJ/ �j�f'
llate last accuracy tested 2�' -/
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
C�IECK ONE:
IR.RIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR?
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: .���1 (i ' �-��� �i,�� � �rJ� `� r
The bacl�low preveation assembly detailed below has beea testod aad maintain� � nq�� bv T'NRCC
regulations aad is cercified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Priaciple e Pressure Vacu�Breaker
9l Double Check Valve ❑ Atmosphere Vacuum Breaker
�7r
Maaufactiaer I�n/��� Siu
Model Nimmber �����/�'�'�Jl � Located At Ge � f�E=����
Serial Nimmber ������
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Cbeck Valve Assembly
lst Check Znd Checi: Relief Valve Air ldet Check Valve
Inival Test DGClosed �- �O Closed Ti,�ht la Opened at Opened at nsid
Ti,ht ¢a Leal:ed o �sid _�sid
RP-_psid
I,eal;ed a �- �- Did aot Opea o Leal:ed o
�P�
and
Mataials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at �sid �
Repair Tight o nsid osid
RP sid
The above is cerdfied to be true.
Fiim Name Ol Accuracy Backflow ���T� C�j�d�(�'� ��,�G�
a on �rc e c
Firm Address FriseQ�1'X 7�Q�� Cat Testa No. '� � d Date �`�c/� '
(iauge # (�/1�1��y
llate last accuracy tested��J7'/�
_._.__.___._,_
White- Customer's Co � Yellow -�
PY y Copy Pink-Tester's Copy
A