2013_0220_RPZ (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL Va IIeu 6 nch tsfi Cuffh
I
LOCATION OF SERVICE: 1 50 I L nQ _ ed . U0 I rJ5UI9
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
,t' Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer W I I k Ks
Model Number 1-7
Serial Number
Size
II
Located At I n P ell 10 100Y S041
1 Canoa
Just inside door
The above is certified to be true.
Firm Name P,rC+ meIrl(- iEWAIN
Firm Address _P.0. Pnx ,7q% Eh W YVA
-nc -1 &nq
Gauge # IA)05HS TV a aG � 6113J"I g
Date last accuracy tested Q.- 3. 1,9-
Certified Tester ZJ
Cent. Tester No. 6POt-) Date
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
RP- 21 sid
Leaked ❑
Closed Tight
Leaked C3
Opened at
:2, �—psid
Opened at
asid
Did not Open ❑
asid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight_ ❑
Opened at
Opened at
_asid
Repair
Tight ❑
asid
asid
RP sid
The above is certified to be true.
Firm Name P,rC+ meIrl(- iEWAIN
Firm Address _P.0. Pnx ,7q% Eh W YVA
-nc -1 &nq
Gauge # IA)05HS TV a aG � 6113J"I g
Date last accuracy tested Q.- 3. 1,9-
Certified Tester ZJ
Cent. Tester No. 6POt-) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy