2015_0901 �5� N.
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 far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: �, .3 I l��`--'TNL�L
CONTACT PERSON/PHONE: N
LOCATION OF SERVICE: '�3� �7
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
�1Reduced Pressure Principle i 1Reduced Pressure Principle-Detector
-f�l�ouble Check Valve C Double Check-Detector
�PressureVacuumBreaker ` ISpill-Resistant Pressure Vacuum Breaker
Manufacturer L'r/rl'T� Model Number
L�f'b� �]"Size 1 ��
Located At ,�(/�Y� � ��Ld�GtN2��'i. ���Serial Number ��, .� J
Is the assembly installed in accordance 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�psid Opened at Opened at Held at
Initial Test Closed Tight,'�f Closed Tight �i' psid psid psid
' �t Leaked! ' Leakedl� Did not open 1 1 Did not open . I Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i.1 Closed Tight��I psid psid psid
Test gauge used:Make/Model (�tJ� vf C E SN:��1�J�S 5
Date Tested for Accuracy: � l / ��
Remarks:
The above is certified to be true at the time of testing.
FirmName `��'iM-141t9,�-���OuJ Firm Address `?1 ! ��, 3�L� ��fQl.r/��j � `���
Certified Tester(pr�nt) ���L� �/ G'f��ertified Tester(signature)
Firm Phone# �/ �7— �/i����6� Cert.Tester No. " Date�/���
* 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