2015_0824 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: �t>� 1'1/�_c�� �-�-; �rv
LOCATION OF SERVICE: '� �iri (y �}�'►7� ��✓1
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
1 Reduced Pressure Principle �Reduced Pressure Principle-Detector
�oubleCheckValve ❑Double Check-Detectar
�IPressureVacuumBreaker I-,Spill-Resistant Pressure Vacuum Breaker
y �r
Manufacturer ���C,,�_Model Number � �� Size �
Located At ���R� l� Serial Number �/� LG�����
Is the assembly installed in acc rdance 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�'�ps' Held at��s� Opened at Opened at Held at
Initial Test Closed Tigly� Closed Tighy7l psid psid psid
Leakedf I Leaked��l Did not open l Did not open ' I Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight�� ] ClosedTight�I psid psid psid
Test gauge used: Make/Model /X/]1L%���'/ �doZ a�7/Lsu SN: � �/�S� �P� 7'
Date Tested for Accuracy: J�'�5��'��
Remarks:
The above is certified to be true at the time of testing.
/ /y ' / � �
Firm Nam� �.S �L � r� l d Firm Address �!/� ///�� �//�'i n� ��
t
Certified Tester(print) %1 ertified Tester(signature)
Firm Phone#��7�'�3 D� Cert.Tester No. � � �� Date Z
* 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