2013_0913 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE K
BACKTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 6p 5,v z `'
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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
%X, Double Check Valve ❑ Atmosphere Vacuum Breaker
(e
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name AIAc
Firm Address P tj" %3u
Gauge # 9 / 7 � ,el'
Date last accuracy tested Ll `5 -/
Certified Testa //"// It
Cent, Testa NoJ11n C0 7 0a Date
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
Tight 3- `7j
Closed Tight
Leaked
Opened at
Sid
Opened at
vSid
vsid
RP -_psid
Leaked Cl
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_vsid
Repair
Tight Cl
oSid
vSid
RP sid
The above is certified to be true.
Firm Name AIAc
Firm Address P tj" %3u
Gauge # 9 / 7 � ,el'
Date last accuracy tested Ll `5 -/
Certified Testa //"// It
Cent, Testa NoJ11n C0 7 0a Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy