2013_0121_RPZ (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:,-ZaSE /Va,g 1a jZl�j Lss Ocala cam.
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.
er Reduced Pressure Principle
❑ Double Check Valve
Manufacturer t,4/. /1k; n 5
Model Number q 757 X I
Serial Number 3 4/9r ';79-S-6
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 3y
Located At "A, 14 - /c , zs{
The above is certified to be true.
Firm Name .9// Ts-1 Certified Tests Zo S e- rt
Firm Address Cent. Tester No. ZRO i3-W/ Date
,O� L-)f Zk -76-9 VV
Gauge # G?o(fA�Ce�
Date last accuracy tested fE_�
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
A55
DC- Closed
Tight
RP- k. v psid
Leaked o
Closed Tight e
Leaked ❑_pSid
7 lc
Opened at
Opened at
______nsid
Did not Open o
_nsid
Leaked n
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ osid
Repair
Tight
Sid
oSid
RP sid
The above is certified to be true.
Firm Name .9// Ts-1 Certified Tests Zo S e- rt
Firm Address Cent. Tester No. ZRO i3-W/ Date
,O� L-)f Zk -76-9 VV
Gauge # G?o(fA�Ce�
Date last accuracy tested fE_�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy