2013_0220_RPZ (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL 1
LOCATION OF SERVICE: )r06I E, O-Q a U I U '15x101
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
a% Reduced Pressure Principle ❑ Pressure Vacuum Breaker
D Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer t 1 l M 5 size `d' 1
Model Number �i 1 Located At Pa l nU rIN o o
serial Number ;N D q u193
The above is certified to be true.
Firm Name rC-1 �jrnZbil f. (�� Certified Tester
Firm Address P-11h0q f A t'I� C«t Tester No.
76171
Gauge # ""CRP 00 y
Date last accuracy tested 1), -3- 12--
no, .
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
P4�)
DC- Closed
Tight
RP- __psid
Closed Tight
Leaked
(y .
Opened at
�•b osid
Opened at
oSid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__.p sid
Repair
Tight ❑
osid
oSid
RP sid-
The above is certified to be true.
Firm Name rC-1 �jrnZbil f. (�� Certified Tester
Firm Address P-11h0q f A t'I� C«t Tester No.
76171
Gauge # ""CRP 00 y
Date last accuracy tested 1), -3- 12--
no, .
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy