2011_1216_RPZ (6)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # Aka �' � 4r -e-P4 : 5 (a q
LOCATION OF SERVICE: 77 m ) - n k &, V ZA
The backilow 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 0, jls Size -/a
Model Number 0 Located At 2r 11 elu C V- J V S ) rl.
Serial Number �-19 a7 09
The above is certified -tto -b' be true.
Firm Name A (l I Certified Tester `e ze 4 411n
Firm Address /C1. !� °1W, 7_%� 7�Zy7Cert Tester No. O 5 Date 1 ' / 4
Gauge # 47&DD6Pq
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
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight X
RP- -J,-�—psid
Leaked ❑
& - 2
3.O psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_psid
Repair
Tight E3
osid
osid
RP sid
The above is certified -tto -b' be true.
Firm Name A (l I Certified Tester `e ze 4 411n
Firm Address /C1. !� °1W, 7_%� 7�Zy7Cert Tester No. O 5 Date 1 ' / 4
Gauge # 47&DD6Pq
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy