2012_1227_RPZCIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1'71 N D UZI U
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
`A Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer W ii5 Size yl2
Model Number Ufay-- Located At unnic-12 -.�Jm morfiirye�
Serial Number TLI o) IL
The above is certified to be true.
Firm Name 1
Firm Address , Z
/, U;?I9S 0/1 xW `7 0
Gauge # 166,'?y�2
Date last accuracy tested 10/
j $//
Certified Tester �EAK/ Vx41g1x i r
Cert. Tester No. `b J?)Q i-30 LL Date 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
PWOTight
DC- Closed
❑
RP- t psid
Closed Tight �r
Leaked ❑
Opened at
�psid
Opened at
osid
osid
Leaked ❑
8 . ®
Did not Open C3
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
flsid
Opened at
_psid
__psid
RP sid
The above is certified to be true.
Firm Name 1
Firm Address , Z
/, U;?I9S 0/1 xW `7 0
Gauge # 166,'?y�2
Date last accuracy tested 10/
j $//
Certified Tester �EAK/ Vx41g1x i r
Cert. Tester No. `b J?)Q i-30 LL Date I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy