2014_0226_RPZ (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE�_
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:1':)U1 G
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.
Reduced Pressure Principle
^_ Double Check Valve
Manufacturer
Model Number 011
Serial Number 0-n U, 1tt -3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size +
Located At ' �i'� k, t c�
The above is certified to be true.
Firm Name 1- i r� i —tip h' Certified Tester L,: / r
z
Firm Address 1 (? n xjl 5� ' : C,(— Cert. Tester No. ` i ►�` Date
Gauge # f t� 11
-,...
Date last accuracy tested ,° f
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
Q.QL9-t%4
DC- Closed
Tight
Leaked Cl
Closed Tight /
Leaked o
Opened at
sid
Opened at
nsid
Did not Opcn ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
nsid
RP psid
The above is certified to be true.
Firm Name 1- i r� i —tip h' Certified Tester L,: / r
z
Firm Address 1 (? n xjl 5� ' : C,(— Cert. Tester No. ` i ►�` Date
Gauge # f t� 11
-,...
Date last accuracy tested ,° f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy