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2011_1216_RPZ (2)CHECK ONE: IRRIGATION DOMESTIC z FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: aark�4 54 -E-4 A 5(.014 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. TYPE OF ASSEMBLY • Pressure Vacuum Breaker • Atmosphere Vacuum Breaker Size -e--Q Ir Located AtJ� D O Reduced Pressure Principle PRESSURE VACUUM BREAKER Double Check Valve Manufacturer O Q 14:f? Model Number © Q2 ry) of Serial Number ALA 19.0 3 TYPE OF ASSEMBLY • Pressure Vacuum Breaker • Atmosphere Vacuum Breaker Size -e--Q Ir Located AtJ� D O The above is certified to be true. 1 Firm Name A l l 'I-e-6 A- Certified Tester 7 o <r Firm Address Tester No. R po Date Gauge # 06#0 0 iQ q Date last accuracy tested Hol/ 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 nsid Tight Leaked ❑ 0 nSid nSid RP $_ g.psid 7 :j> SS ; Cl Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at —_---p sid Repair Tight ❑ nSid nSid RP Sid The above is certified to be true. 1 Firm Name A l l 'I-e-6 A- Certified Tester 7 o <r Firm Address Tester No. R po Date Gauge # 06#0 0 iQ q Date last accuracy tested Hol/ White - Customer's Copy Yellow - City Copy Pink - Tester's Copy