2013_1218_RPZ (2)CHECK ONE:
IRRIGATION
DOMESTIC
V/
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
:1a 5 0 -F—
LOCATION OF SERVICE: IV k&X- Y7 -%P--t
75 N. ,)D,-"l P n J P
The back-flow prevention as detailed below has been tested and maintained as required by TNRCC
re¢ulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
❑ Double Check Valve
Manufacturer J2)a �5—
Model Number (60191y2—
Serial Number 6%320,3
TYPE OF
Size
ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Located At M
-! �e 61P M-a f e-f S Y -e� -
The above is certified to be true.
Firm Name Aff � Certified Tester, if r- A)4 "l
Firm Address .af-, Gf/D% ,r 1 �! � crt Testa No. O 8( Date —IF-13
Gauge # Q O 7
Date last accuracy tested % 10 13
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
j.5
DC- Closed
Tight �
RP -. Sid
Closed Tight X
Leaked 13
Ced at
.60 DSid
Opened at
vSid
vsid
Leaked p
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
DSid
vsid
RP sid
The above is certified to be true.
Firm Name Aff � Certified Tester, if r- A)4 "l
Firm Address .af-, Gf/D% ,r 1 �! � crt Testa No. O 8( Date —IF-13
Gauge # Q O 7
Date last accuracy tested % 10 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy