2014_0129_RPZCHECK ONE:
IRRIGATION
DOMESTIC .�
FIRELINE
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer _�`.vj Size _.t.
9
W
Model Number �� ' Located At
Serial Number 3 6
The above is certified to be true.
Firm Name ) " 1-,')L � !�" �ertified Testa
Firm Address 6 i rN Cent. Tester o ` Date
Gauge # O) b d 1 i K
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
Closed Tight
ed at
Opened at
nsid
Tight ?, S�
RP -_psid
Leaked
psid
nsid
Leaked o
y
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_psid
Repair
Tight o
nsid
�osid
RP sid
The above is certified to be true.
Firm Name ) " 1-,')L � !�" �ertified Testa
Firm Address 6 i rN Cent. Tester o ` Date
Gauge # O) b d 1 i K
Date last accuracy tested`��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy