2013_0220_RPZCHECK ONE:
IRRIGATION
DOMESTIC V/
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICEIRI F • 6W (,&u fA D ILL 72-c If 0
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
Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C. Atmosphere Vacuum Breaker
Manufacturer 1 (kl Size •�a1.M
S"
Model Number aO q Located At
Serial Number I L U 07oZ
The above is certified to be true.
Firm Name J A� 6 rt-+ DOrnVA r . l rt1 Gj Certified Tester
Firm Address P 0 • `1a S $ Cert. Testa No. �� wiLvoL Date 3
F� w-o� �Ik�lcot�9
Gauge # Wxds (Kqa E 01317 16
Date last accuracy tested 11. 3. 1 a—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
1
DC- Closed
Tight
RP- l„ , � osid
Leaked ❑
Closed Tight
Leaked ❑
t�
Opened at
Z• 2 psid
Opened at
ysid
Did not Open ❑
psid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
psid
Opened at
psid
psid
RP sid
The above is certified to be true.
Firm Name J A� 6 rt-+ DOrnVA r . l rt1 Gj Certified Tester
Firm Address P 0 • `1a S $ Cert. Testa No. �� wiLvoL Date 3
F� w-o� �Ik�lcot�9
Gauge # Wxds (Kqa E 01317 16
Date last accuracy tested 11. 3. 1 a—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy