2013_0613CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: !7 �� '' e t
The back-Low 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 C Atmosphere Vacuum Breaker
Manufacturer j Size a�
Model Number Ci f�f Located At
Serial Number S
JUM BREAKER
Check Valve
osid
Leaked C
osid
The above is certified to be true.
Firm Name & T) C aL- /' fc Certified Tester k'L f�i . JW s
Firm Addrresss y 7i % t��k9 - Cent Tester No. �� � �' Date /3
Gauge # 0 6 t) q) 7Y 0
Date last accuracy tested V "s ",/ 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC-Closed
Tight
Closed Tight X
Leaked C
Opened at
osid
Opened at
osid
RP- ,__psid
Leaked C
Did not Open o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
Repair
Tight C
psid
osid
RP sid
JUM BREAKER
Check Valve
osid
Leaked C
osid
The above is certified to be true.
Firm Name & T) C aL- /' fc Certified Tester k'L f�i . JW s
Firm Addrresss y 7i % t��k9 - Cent Tester No. �� � �' Date /3
Gauge # 0 6 t) q) 7Y 0
Date last accuracy tested V "s ",/ 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy