2013_1218_RPZ (7)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: mar-
The bacldlow prevention 20, detailed below hasnbeed tested`
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
as required by TNRCC
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size T
Located At Tr�i �n die r �rI k
Reduced Pressure Principle
C
Double Check Valve
Manufacturer
-s
Model Number
O0�
Serial Number
-� to z S 7c
TYPE OF ASSEMBLY
as required by TNRCC
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size T
Located At Tr�i �n die r �rI k
The above is cafiAed to be true.
Firm Name Certified Tester Y
Firm Address - *�/Cert. Testa No. Date
Gauge # A�0717 ,OV
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
S5
DC-Closed
Ti®
RP � cO DSid
Leaked C
Closed Tight
Leaked o
S
Open at
pen Sid
Opened at
nSid
Did not Open C
nsid
Leaked ❑
Repairs
and
Materials
Used
fter
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
L
Tight o
nSid
nSid
RP Sid
The above is cafiAed to be true.
Firm Name Certified Tester Y
Firm Address - *�/Cert. Testa No. Date
Gauge # A�0717 ,OV
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy