2014_0324CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 137 R,'
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.
C Reduced Pressure Principle
ram Double Check Valve
Manufacturer IJm S
Model Number Oa
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be truePlo,"keCl Firm Name
Certified Tester C GS
Firm Address 2 q31 z F / Cert. Tester No. Date
Gauge # &, /)
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
DC- Closed
Closed Tight
Opened at
Opened at
oSid
Tight
It - `_,DSid
Leaked Z ❑
2
nsid
_oSid
Leaked ❑
Did not Open O
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_oSid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be truePlo,"keCl Firm Name
Certified Tester C GS
Firm Address 2 q31 z F / Cert. Tester No. Date
Gauge # &, /)
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy