2013_0925_RPZCHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: dn- km dkffl C c
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.
a Reduced Pressure Principle
❑ Double Check Valve
Manufacturer atm-
Model Number r'-;� CLO 6
Serial Number 15 W
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size )
Located At
The above is certified to be true. Llel-my-j)
Certified Testa
Firm Address c z c Cat. Testa No.PJQ016-7 73 Date 9 � S'
Gauge # 17 2 3 5 3
Date last accuracy tested/ - d =3 - 13
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
DG- Closed
Closed Tight a
Opened at
Opened at
nsid
pe,55
Tight M
RP- " L psid
Leaked ❑
Leaked ❑
asid
nsid
Did not Open ❑
Leaked ❑
Reps
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. Llel-my-j)
Certified Testa
Firm Address c z c Cat. Testa No.PJQ016-7 73 Date 9 � S'
Gauge # 17 2 3 5 3
Date last accuracy tested/ - d =3 - 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy