2013_0919_RPZCHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �' r t dy/1 — 1-7 17 E e
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
V"' Reduced Pressure Principle a Pressure Vacuum Breaker
n Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number D 091 lit Located At otd.o 13 e.
Serial Number �' 0'? 7 0
The above is certified to be true.
Firm Name i Ldd e- D i xe✓ Certified Tester ' e-.,,
Firm Address Pa x r�la�� �ZY—r
Cert. Tester Nol 't? j ham' -S Date
Gauge # 20 a (I to
Date last accuracy tested_
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
nsid
Tight
Leaked ❑
_psid
�vsid
RP -_psid
Leaked ❑..e
Did not Open ❑
Leaked O
Repairs
kiUU4
and
f a0�
Materialsf�
�-�-
�a`lY► ; r
Used
Test After
DC- Closed
Closed Tight AT
Opened at
Opened at
__nsid
Repair
Ti 1�
14`
-3w sid
osid
RP s V sid
The above is certified to be true.
Firm Name i Ldd e- D i xe✓ Certified Tester ' e-.,,
Firm Address Pa x r�la�� �ZY—r
Cert. Tester Nol 't? j ham' -S Date
Gauge # 20 a (I to
Date last accuracy tested_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy