2014_0306CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: lO 1
The backilow 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
Double Check Valve C7 Atmosphere Vacuum Breaker
Manufacturers `3 Size
Model Number C' Located At T tom-- r. L ' `y
Serial Number %� (` T(2 Z?
The above is certified to be true. n
Firm Name
(>�DA 121 - Certified Tester SD 6
Firm Address � ✓� Cert. Tester No. I S - Date 3 _L,
Gauge #
Date last accuracy tested Z — 5---1 3
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
RP- Z/
Leaked o
oSid
nSid
Dsid
Leaked p
3
Did not Open o
Leaked
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight 13
nSid
oSid
RP sid
The above is certified to be true. n
Firm Name
(>�DA 121 - Certified Tester SD 6
Firm Address � ✓� Cert. Tester No. I S - Date 3 _L,
Gauge #
Date last accuracy tested Z — 5---1 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bac0ow 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve G Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name Certified Tester
Firm Address 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 Cheri:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
vSid
osid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
vSid
Opened at
vSid
vsid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cert. Tester No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
GANDARA IRRIGATION INC.
3901 Clifton Dr. Richardson TX 75082
Office: 972 - 671 -3776
Fax: 972 - 664 -9158
Cell: 972 - 467 -3918
Email: eddiegan1 @sbcglobal.net
City of Coppell TX
101 RIDGECREST CT
This irrigation systemhas been installedin accordance with all applicable
State and local laws ,ordinances, rules, regulations and orders.
I have tested the system and determined that it has been installed according
to the irrigation plan and is properly adjustedfor the most efficient
application of water at this time.
1 year warranty from the day of installation.
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