2011_1216_RPZ (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # AAar 1�f 4' S-�rp—�4 Jc e I
LOCATION OF SERVICE: �� ✓`P"� l n a
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
. Reduced Pressure Principle
❑ Double Check Valve
Manufacturer , wa4t5
Model Number 00,3
Serial Number At0 g,3 45
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size Z
Located At
The above is certified to be true.
�L
Firm Name /� f�ST Certified Tester
Firm Address . 7)( ?b 2!/�/ Ccrt. Tester No. >8 A 01'3 5 y / Da Z-/ (0 -
Gauge # LS)&110e.)k5
Date last accuracy tested a ((
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 15-.a
RP- _psidx
Leaked o
Closed Tight X
Leaked ❑
$ 2
Openeg at
d sid
Opened at
osid
Did not Open o
osid
Leaked E3
Repairs
and
Materials
Used
Test Mier
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
osid
_psid
RP sid
The above is certified to be true.
�L
Firm Name /� f�ST Certified Tester
Firm Address . 7)( ?b 2!/�/ Ccrt. Tester No. >8 A 01'3 5 y / Da Z-/ (0 -
Gauge # LS)&110e.)k5
Date last accuracy tested a ((
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy