2013_0129 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE. Z/
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # C��
LOCATION OF SERVICE:
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.
TYPE OF ASSEMBLY
e Reduced Pressure Principle 12 Pressure Vacuum Breaker
Double Check Valve O Atmosphere Vacuum Breaker
3
Manufacturer lit- 9 Size 1V
Model Number CZ 22 `"> ? Located At UAw /�-
Serial Number 2Z> W 0
Date last accuracy tested a • FS- In_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
' f Valve
Air Inlet
Check Valve
1st Check
2nd Check:
Initial Test
4-55
DC- Closed
Tight 2 Z
RP--- sid E3
Closed Tight
Leaked
Z- 4
❑
Opened at
nsid
Opened at
nsid
Did not Open C3
_psid
Leaked o
Reps
and
Materials
Used
Test After
Repair
DC- Closed Closed Tight
Tight C3
Rp sin
O Opened at
vsid
Opened at _ Dsid
sid
The above is certified to be true.
Firm Name
145-4 vnA, r,-J,5,t Vi c"o
Firm Address T � `�"k Zz.
Certified Tester rG�l?�N �.Oaa�J
Cert. Tester No.ZPm 135-q Date ,
Date last accuracy tested a • FS- In_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy