2011_1216_RPZ (8)CHECK ONE:
IRRIGATION
DOMESTIC VX FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # Mar k- 4 4- 5(p q
LOCATION OF SERVICE:
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.
Reduced Pressure Principle
Double Check Valve
Manufacturer U) 0. - ' 45
Model Number 00
Serial Number A (o a $y O
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
`eZrr
Located At )Ae�+ -De P 4 • G[rid,,e r i5i ry k-
The above is certtified to be true.
Firm Name lilt
Certified Tester a�'l
Firm Address Cent Tester No. SP ,0°/36 Date / Z—1 (o'Il
Gauge # _D(p) l00[oq
Date last accuracy tested S -15H1
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 /
1 ,
Leaked ❑
�i �O
�•� _pSid
nSid
5
RP- -- .sid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Sid
Repair
Tight ❑
esid
nSid
RP sid
The above is certtified to be true.
Firm Name lilt
Certified Tester a�'l
Firm Address Cent Tester No. SP ,0°/36 Date / Z—1 (o'Il
Gauge # _D(p) l00[oq
Date last accuracy tested S -15H1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy