2013_0311_RPZCHECK ONE:
IRRIGATION
DOMESTIC V
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
r LC.�S
LOCATION OF SERVICE: S 1 ?
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 A)
Model Number t� t`7
Serial Number `-3 3` �-
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size Lrs Lo0d LJdC (i p 4eh�
Located At - �, IC Aw'0- 1
The above is certified to be true.
Firm Name i . 'C, ( e Certified Tester 1`6 _ ff 11-Y J
C
Firm Address j DO Cert Tester No. 9,4DO 0 1 12< Date
be, #Q's f T< tqt 3
Gauge # �j_ 4 ja 13 n (
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
Tight ❑
RP --2—psid
Leaked ❑
Closed Tight ❑
Leaked ❑psid
Opened at
Opened at
osid
Did not Open O
osid
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name i . 'C, ( e Certified Tester 1`6 _ ff 11-Y J
C
Firm Address j DO Cert Tester No. 9,4DO 0 1 12< Date
be, #Q's f T< tqt 3
Gauge # �j_ 4 ja 13 n (
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy