2014_0214 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
I)) I-) ( e /2. P c' -T C r
The back-flow 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
Double Check Valve
Manufacturer -Fi C
Model Number Ily yZi
Serial Number ft C. - 7 5G 1
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size / Y
Located At
Gandara [Mgatron
The above is certified to be true. 901 Cron Dr.
Rirh3nrdsnn. 7X. 75032
Firm Name nd a tm
Richardson, Tx. 75082
Firm Address
Gauge # j / % 6 5-7"1
Date last accuracy tested /, -
Certified Tester
Cert. Tester No. A, f LY ) S15L. 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
Tight .. d
RP- !I psid
Leaked ❑
Closed Tight e
Leaked ❑
Opened at
vsid
Opened at
osid
Did not Open ❑
vsid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
vsid
Opened at
osid
____— nsid
RP Sid
Gandara [Mgatron
The above is certified to be true. 901 Cron Dr.
Rirh3nrdsnn. 7X. 75032
Firm Name nd a tm
Richardson, Tx. 75082
Firm Address
Gauge # j / % 6 5-7"1
Date last accuracy tested /, -
Certified Tester
Cert. Tester No. A, f LY ) S15L. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy