2015_0901 /�/l%�d�
IRRIGATION DOMESTIC FIRELINE
The following form must be completed for 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 I.D. # 0570040
(Customer) �
MAILING ADDRESS: ���`�_�E���L
CONTACT PERSON/PHONE: l✓I J4,�Yi�'y��
LOCATION OF SERVICE: �'j� ,S ���1-I�L
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
IR�e ced Pressure Principle `=1Reduced Pressure Principle-Detector
i�1'DoubleCheckValve -1Double Check-Detector
❑PressureVacuumBreaker ���I Spill-Resistant Pressure Vacuum Breaker
Manufacturer �lif/��l`J Model Number � F �B�/�-�� Size�
Located At�/'1/1��� Jr��d.�QiI���C. � Serial Number ��Or3 0��
Is the assembly installed in accardance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held at��sid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid �' psid psid
Leakedf' LeakedC Did not open I I Did not open ._] Leaked. I
Repairs/
Materials
Used
�
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight_� Closed Tight'J psid psid psid
G���
Test gauge used: Make/Model �9 SN: _ :
Date Tested for Accuracy: �
Remarks:
The above is certified to be true at the time of testing.
Firm Name �/(-i�l/11���4-C.Cr�irm Address ���G���(o�}�i4lc/�/2���`�c.S�G �—'
Certified Tester(pr:nt) �l��Z J�iC� Certified Tester(signature)
Firm Phone# �2_��'�G� -�Zc�Z_Cert.Tester No. p � 15 Date � !�Z/ �/6
* 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