2013_1218_RPZCHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Mox 4 S4 f--e �e 4 5&
%O 0. 4 ors —74P A
The back-flow prevention assembly detailed below has been tested and
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer 104-45
Model Number 0 y I
Serial Number 4'70
TYPE OF ASSEMBLY
maintained as required by TNRCC
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At !Jf 1 K' �` 'r �'l �/� /t r r �1 n
The above is certified to be true. _
Firm Name �� F-0 5� Catfiied Tester
Firm Address Gl/o/ ; l 'X 2 %Cert. Tester No.181000I51784P Date /-�L / F /3
Gauge # 01/,0 = 79y
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 ❑
ed at
Opened at
osid
'i
Tight ❑
RP- 4 psid
Leaked
�,sid
osid
L,ea;ed
Did not Open O
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight
Op at
Opened at
osid
Repair
Tigh y
D
_ psid
osid
RP • sid
The above is certified to be true. _
Firm Name �� F-0 5� Catfiied Tester
Firm Address Gl/o/ ; l 'X 2 %Cert. Tester No.181000I51784P Date /-�L / F /3
Gauge # 01/,0 = 79y
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy