2011_1216_RPZ (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL r
PWS I.D. # � 0.� r�-t
LOCATION OF SERVICE: %D D /V
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is cernified to be operating within acceptable parameters.
xReduced Pressure Principle
❑ Double Check Valve
Manufacturer .lL OLS
Model Number 009
I
Serial Number -4 7 Rod a 5
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size g A
Located At 5 rL qe- 4 r ,56 Lsl- a KO om
The above is certified to be true.
Firm Name &I /Q
Certified Tester A 7`/'7 1--el 4 n
Firm Address F-1 f t/ai yU , '17Y-7&0&t Tester No. 910996V,3 Date /07 /& `//
Gauge # 0&// a O loq
Date last accuracy tested 8- %-,-/1
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 -nsid
Leaked p
Closed Tight )RC
Leaked ❑
• 41
Opened at
a rTpsid
Opened at
nsid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test Af%t
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
_n sid
RP psid
The above is certified to be true.
Firm Name &I /Q
Certified Tester A 7`/'7 1--el 4 n
Firm Address F-1 f t/ai yU , '17Y-7&0&t Tester No. 910996V,3 Date /07 /& `//
Gauge # 0&// a O loq
Date last accuracy tested 8- %-,-/1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy