2014_0226_RPZCHECK ONE:
IRRIGATION
DOMESTIC
V--�
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
:'S, -Uv
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 par.=eters.
Reduced Pressure Principle
❑ Double Check Valve
Manufacturer l 1."�'
Cif,
Model Number '� ,�!
Serial Number 1(_l g 712
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
G Atmosphere Vacuum Breaker
jj ,r
Size L
Located At
The above is certified to be true.
Firm Name - ,;► '`� Safi ` . (� �` Certified Tester „ � , A,1-7 JA `W
Firm Address' t � 'T1 121 ,� X Cert. Tester No. i W'e 1 ,.1Z Date %'
Gauge #
Date last accuracy tested i °.X --T 1 aT
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
Tight,
Closed Tight
Leaked ❑_psid
Opened at
Opened at
vSid
vsid
a k`A
RP- L.bsid
Leaked ❑
�% y
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
vsid
vSid
RP sid
The above is certified to be true.
Firm Name - ,;► '`� Safi ` . (� �` Certified Tester „ � , A,1-7 JA `W
Firm Address' t � 'T1 121 ,� X Cert. Tester No. i W'e 1 ,.1Z Date %'
Gauge #
Date last accuracy tested i °.X --T 1 aT
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy