2013_0607CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINT ENANC'E REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # —
LOCATION OF SERVICE: Yl t �� � � - ti
The bacidlow prevention assembly detailed below has been tested and mmmmed as required by TNRCC
reguianons and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
❑/ Double Check Valve
Maaufact= 1 - i an
Model Number 3 D
Serial Number � R 9 1
TYPE OF ASSEMBLY
Q Pressure Vacmun Breaker
❑ Amuosphere Vacuum Breaker
Size / f ► DC
Located At F r0 R j OF 1A U r1c� r Y
The above is certified to be true.
Firm Name CIS rl U-, Pk Certified Tests
Fnm Address <� -1Z, - , -V,! ) , Cat Tests N - ) � �)
Gauge # G'10 C0 1�
Date last accuracy tested
Cam- 7 -13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAI=
Double Check Valve Assembly
Relief Valve.
Air Inlet
Check Valve
1st Check
2nd Clad:
initial Test
P�sS
1 >,a5 -13
DC- Closed
T,& ), �
RP -_psid
Leaked o
Closed Tight er
Leaked 9 0
v�
Opened at
--psid
Opened at
-- �psid
Did not Open o
id
tad
Rzpairs
and
Materials
Used
Teat After
Repair
I DC- Closed
Tight ❑
Closed Tight o
OPMW at
osid
Opened at
__psid
d
RP
The above is certified to be true.
Firm Name CIS rl U-, Pk Certified Tests
Fnm Address <� -1Z, - , -V,! ) , Cat Tests N - ) � �)
Gauge # G'10 C0 1�
Date last accuracy tested
Cam- 7 -13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy