2013_0506CHECK ONE:
IRRIGATION DOMESTIC FIRELINE_ZVL 4j
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: `l0C) INi V; c r K d
The back-flow prevention assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Z; Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Wy '-1 � Size 3f`/
Model Number 0C %7 'noo Located At ., 'r t 7-v,, (,7C o
Serial Number 1 > 96
The above is certified to be true.
Firm Name 4(, -r e ►,V C^ z C
Firm Address 6 ) fxj x `7 Ci 7
i cya hc.c
Gauge # iC) &
Date last accuracy tested _31,13
Certified Testa NtJ,2--iv-C. lul,e ti vt e e
Cat. Testa No. WO ri,!) 7" Date 5J61/3
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 Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
flsid
Tight 4.,,- C
RP -_psid
Leaked ❑
Dsid
osid
leaked V
1
Did not Open ❑
Leaked ❑
Repairs
e. r
and
Materials
�' e l-
Used
Test After
Repair
DC- Closed
Tight 0. -11 W?.
Closed Tight d
Opened at
nsid
Opened at
osid
_nsid
RP sid
The above is certified to be true.
Firm Name 4(, -r e ►,V C^ z C
Firm Address 6 ) fxj x `7 Ci 7
i cya hc.c
Gauge # iC) &
Date last accuracy tested _31,13
Certified Testa NtJ,2--iv-C. lul,e ti vt e e
Cat. Testa No. WO ri,!) 7" Date 5J61/3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy