2011_1216_RPZ (5)CIIECK ONE:
IRRIGATION
DOMESTIC
V/-"�
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
64P
r %
LOCATION OF SERVICE: %Op IV, Drn ton P aC
The back-flow prevention assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
XReduced Pressure Principle
Double Check Valve
Manufacturer w a- 4- 47s
Model Number 001—
Serial Number A b 2 S'�7 O
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
n
Size
Located At A6 ✓t J to r-
The above is certified to be true.
Firm Name N1 / Te s+ Certified Tester o n
Firm Address /ef �-%,_ �%� Cert. Tester No. 13900 136 ( Date i Z= I (o`t J
Gauge # t) (01(00 (o q
Date last accuracy tested 9-V-11
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
]�i;,�
DC- Closed
Tight
RP -nsid
Closed Tight
Leaked o
7 • q
ed at
�sid
Opened at
nsid
esid
Leaked o
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
Repair
DC-Closed
Tight o
Closed Tight o
Opened at
nsid
Opened at
nsid
_nsid
RP sid
The above is certified to be true.
Firm Name N1 / Te s+ Certified Tester o n
Firm Address /ef �-%,_ �%� Cert. Tester No. 13900 136 ( Date i Z= I (o`t J
Gauge # t) (01(00 (o q
Date last accuracy tested 9-V-11
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy