2014_0425_RPZCIIECK ONE:
R P Z--
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bac0ow 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 ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer - Size OW
Model Number & Located At
Serial Number Z- 7-06 -' `
The above is certified to be true.
Firm Name Certified Tester.
r
Firm Address k K- A.Q 'I.�J�2e�X ,4ert. Tester No. !/ Date
7&t�.t- /.c
Gauge # &G,(? � &,7
Date last accuracy tested /2 l-z -/j
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 t
Opened at
osid
Tight ❑
Leaked ❑
Leaked o
- Sid
oSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
--.p sid
Repair
Tight 13
nsid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester.
r
Firm Address k K- A.Q 'I.�J�2e�X ,4ert. Tester No. !/ Date
7&t�.t- /.c
Gauge # &G,(? � &,7
Date last accuracy tested /2 l-z -/j
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy