2013_0220_RPZCIIECK ONE:
IRRIGATION
DOMESTIC
V/,*"
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SER
CITY OF COPPELL
3
!Z8
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.
V"'
Reduced Pressure Principle
❑ Double Check Valve
Manufacturer ( IK:. _
Model Number _ �0-5 vv,�
Serial Number
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
Q Atmosphere Vacuum Breaker
Size
Located At 6)`{�y�'�
The above is certified to be true.
Firm Name l l� F-t re-t T'n 4rr r IEsTr.J C? Certified Tester
Firm Address f 0,15 OIL -1C1514 8 `FW j-y Cent. Tester No. -DOCK l I H b Z Date o7 Ln -
Gauge # m# s AqC( Oo -1311 r
Date last accuracy tested � a- 3 � I '-)--
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 X
Closed Tight
Leaked ❑
0p qued at
psid
Opened at
nsid
nsid
RP- J.C� psid
Leaked ❑
1.6
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name l l� F-t re-t T'n 4rr r IEsTr.J C? Certified Tester
Firm Address f 0,15 OIL -1C1514 8 `FW j-y Cent. Tester No. -DOCK l I H b Z Date o7 Ln -
Gauge # m# s AqC( Oo -1311 r
Date last accuracy tested � a- 3 � I '-)--
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy