2013_0716 (24)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `flak C�eC4 SSG &6l AV e r c AAfc h r. 7Sd/ <t
The baciflow 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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve Ell Atmosphere Vacuum Breaker
/
Manufacturer Ai".
� ` ✓i.�/( X11. S Size
Model Number J 6,kL Located At I "5-C' Y- ro o /W ASS
Serial Number Ca A ?0/-/
The above is certified to be true.
Firm Name Zietr o
Firm Address Po tA i4L- '
/x 766 9
Gauge # 080 -/O ;5„5Q
Date last accuracy tested / z
Certified Tester �O— r !
Cert. Tester No /? /'NG6 8'66 9 Date //G
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
vSid
Tight ❑
RP -_ DSid
Leaked ❑
psid
vSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
nsid
DSid
RP sid
The above is certified to be true.
Firm Name Zietr o
Firm Address Po tA i4L- '
/x 766 9
Gauge # 080 -/O ;5„5Q
Date last accuracy tested / z
Certified Tester �O— r !
Cert. Tester No /? /'NG6 8'66 9 Date //G
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy