2015_0901 �vq',�
IRRIGATION DOMESTIC � FIRELINE
The following form must be completed far each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer)
MAILING ADDRESS: �/���y'�L�I
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �/ff ��"���L
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�`-]Reduced Pressure Principle C-Reduced Pressure Principle-Detector
�Plouble Check Valve I Double Check-Detector
�PressureVacuumBreaker C Spill-Resistant Pressure Vacuum Breaker
Manufacturer W/4j7s Model Number� F '7�v1/ Size�
Located At���� .Lr.CO„�1��_n� �n,��,�Serial Number �Z � ��1�r�
`
is the assembly installed in accordance with manufacturer recommendations and/or local codes? Y��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air lnlet Check Valve
1 st Check 2nd Check
Held at�psid Held at�psid Opened at Opened ax Held at
Ini ia Test Closed Tightl� Closed Tight.� psid psid � psid
Leaked. 1 Leaked�1 Did not open . I Did not open [�-� Leaked�l i
Repairs/
Materials �'`
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� I Closed Tight����-1 psid psid psid
Test gauge used: Make/Model SN:��7 Q � , �
Date Tested for Accuracy: � 0�i a� ��
Remarks:
The above is certified to be true at the rime of testing.
FirmName /�_��f��—i✓S �ig�rlrm Address�/�li� c���r� ���'/�,� �' 7�6Ci
Certified Tester(pr:nt) V� �4 Gl�rri.�ertified Tester(signature)
Firm Phone# ��Z,`�te�� �7i Cert.Tester No. ���1 Date D ��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy