2013_0122 (7)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CTY OF COPPELL
LOCATION OF SERVICE:
J
The backflow 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer A-co, e .�s Size
Model Number � ' -) c) Located At
Serial Number
The above is cccr�tified to be true.
Firm Name! c' Certified Tester _ &4i•' Ja,14cl�
Laos Z� z s -act
Firm Address ,$-Io4 P z-r' � 167,0q6 Cent. Testa No� le-1-73 Date � °� 3
Gauge # 37aZ
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
p�5-5
DC- Closed
Tight- -� Ak
sid
Leaked ❑
Closed Tight �T
Leaked ❑
y
Opened at
vsid
Opened at
vsid
Did not Open ❑
vsid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
vsid
Opened at
vsid
vsid
RP sid
The above is cccr�tified to be true.
Firm Name! c' Certified Tester _ &4i•' Ja,14cl�
Laos Z� z s -act
Firm Address ,$-Io4 P z-r' � 167,0q6 Cent. Testa No� le-1-73 Date � °� 3
Gauge # 37aZ
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy