2013_0823_RPZCHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
'4
LOCATION OF SERVICE: 'I o5 V
-n ra.
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
Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer An0 110
._I -
Model Number L4 Q a0 aT2 t>
Serial Number Z Y. vim` D
Size 3/4
Located At Iwe(��nu�,n� Gw1 r ry
The above is certified to be true.
Firm NameV� � Certified Tester
Firm Address 45`1`d tA&A � N a U Cert. Tester No. V00L, YQ Date
Wo r ; �4;ZLV '
Gauge # 0&011'1jq
Date last accuracy tested `1 p
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
Ti
�Dsid
Closed Tight
Leaked ❑
Opened-at
-psid
Opened at
osid
osid
L
�J
R p- -L
Leaked ❑
• �e
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__ nsid
Rtpair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm NameV� � Certified Tester
Firm Address 45`1`d tA&A � N a U Cert. Tester No. V00L, YQ Date
Wo r ; �4;ZLV '
Gauge # 0&011'1jq
Date last accuracy tested `1 p
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy