2014_0325CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1S � {, I L- -e -r'1
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulanons and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
,L;r Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At r
The above is certified to be true.
Firm Named C L-L, kj Certified Tester
Firm Address ,��'25-t 32 Cert. Tester No. E eW Date /
Gauge # l
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
Tig r
RP _psid
Leaked ❑
Closed Tight
Leaked ❑
Opened at
osid
Opened at
osid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
flsid
_osid
RP psid
The above is certified to be true.
Firm Named C L-L, kj Certified Tester
Firm Address ,��'25-t 32 Cert. Tester No. E eW Date /
Gauge # l
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy