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2014_0213 (12)CHECK ONE: IRRIGATION DOMESTIC FIRELINE J BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #:��1�C LOCATION OF SERVICE: UQ 5o)Q#1 The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. e Reduced Pressure Principle Double Check Valve Manufacturer s b C. Model Number S 1) Y Serial Number 'i� r-- LA Q 7 TYPE OF ASSEMBLY M Pressure Vacuum Breaker C Atmosphere Vacuum Breaker Size I Located At ��CZ The above is certified to,be true. Firm Name TA �\\ ` \' ' k, . Firm Address a C 5 1 ©hMA5 Tx 75 7 Gauge # � 7 <6 9 Date last accuracy tested -1 �Ce- rte_ Certified Testers Cent. Tester No Date 13 I White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Check 2nd Chest: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight .Opened at Opened at nsid Tight o RP -_psid Leaked Leaked sid _osid Did not Open O Leaked O Reps and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at --_____p sid Repair Tight o _ nsid nsid RP sid The above is certified to,be true. Firm Name TA �\\ ` \' ' k, . Firm Address a C 5 1 ©hMA5 Tx 75 7 Gauge # � 7 <6 9 Date last accuracy tested -1 �Ce- rte_ Certified Testers Cent. Tester No Date 13 I White - Customer's Copy Yellow - City Copy Pink - Tester's Copy