2013_0925_RPZ (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
lfi Reduced Pressure Principle
❑ Double Check Valve
Manufacturer \_ y-x -C- 5
Model Number C C
Serial Number 13 � C')
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Located At � L, "'N cI c c
The above its certified to be true.
Firm Name T cL Certfied Tester 221a41W SaT-)CIQWM/
aaas CK
Firm Addrns XA1(- ,1 cL .L "Z 5`,D q CV Cent. Tester No 0,06 / o 7 7,3 Date
Gauge # 3--2 2 3 S 3
Date last accuracy tested I -a 0, / 3
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
osid
S `j
Ti2ht ❑
RP- - ` sid
Leaked ❑
Leaked ❑
^�
' U
vsid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_osid
Repair
Tight ❑
nsid
osid
RP sid
The above its certified to be true.
Firm Name T cL Certfied Tester 221a41W SaT-)CIQWM/
aaas CK
Firm Addrns XA1(- ,1 cL .L "Z 5`,D q CV Cent. Tester No 0,06 / o 7 7,3 Date
Gauge # 3--2 2 3 S 3
Date last accuracy tested I -a 0, / 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy