2015_1027 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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � ;�'� c'"rfl�-:-`?� �- ="l �"`'._r,�,�"� ��
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
]R�e uced Pressure Principle -1Reduced Pressure Principle-Detector
�oubleCheckValve 7Double Check-Detectar �
-�PressureVacuumBreaker _7Spill-Resistant Pressure Vacuum Breaker ',
Manufacturer (,u r �:. '; ,,- � Model Number -�`�'"� Size�
Located At � ������:�� f� t�:� �•7�1 �Serial Number/Q � ��� '<�� �
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�� � psid Held a��� psid Opened at Opened at Held at �
Initial Test Closed Tightl i Closed Tight G psid psid psid �
Leakedf I Leaked-I Did not open ❑ Did not open f ' Leakedi I
Repairs/
Materials
Used
Held at psid Held at psid �
Test After Opened at Opened at Held at
Repair ClosedTight� ClosedTight❑ psid psid psid
�-.U1�rf.s�%!✓,� C C,��-- r_
Test gauge used: Make/Model �i�'� ��r✓ /�<<./ SN:t.1''���� ����' ! � �
Date Tested for Accuracy: ��f ��' `7 �
Remarks:
The above is certified to be true at the time of testing.
.-� _. -�
FirmName � � _.L__d%�� Firm Address�Cfs� ��:=.� �f t/��:�,� �>./��- ✓f�G. (�
l � _.. / ..
Certified Tester(pr;nt),f�i d,�.rri�,�L: �'.�vs��F�`� Certified Tester(signature)�`,/' r``�'''��'�r ��='f t-��%�(
_. �^ , ,+
Firm Phone#�1�� `i r���- � � ��l Cert.Tester No. �`� �� Date/U /�'7.����W
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Ye11ow-Customer Copy Pink-Tester's Copy