2014_0213 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 10!q 1 �� t �, `� ( c., 7"
The bacidiow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ / Reduced Pressure Principle
2� Double Check Valve
Manufacturer p e
Model Number
Serial Number tic -
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size J /�
Located At
The above is certified to be true.
Firm Name Gandara Irrigation
Richardso�082
Firm Address
Gauge # .317 G�
Date last accuracy tested
Certified Tester
Cent. Testa No. Date
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
nsid
Tight ❑
Leaked ❑
nSid
nSid
RP -_psid
I„ naked ❑
Did not Open ❑
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nSid
nSid
RP sid
The above is certified to be true.
Firm Name Gandara Irrigation
Richardso�082
Firm Address
Gauge # .317 G�
Date last accuracy tested
Certified Tester
Cent. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy