2015_1012 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) �, 1
MAILING ADDRESS: �O �� �l^J�GI�y �
CONTACT PERSON/PHONE: "
LOCATION OF SERVICE: ti�1� v�u v�
The backflow prevention asseinbl�led below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� � IReduced Pressure Principle �Reduced Pressure Principle-Detectar
1 Double Check Valve I�Double Check-Detector
i 'Pressurc Vacuum Breaker i 'Spill-Resistant Pressure Vacuum Breaker
Manufacturer �-8 �'c�' Model Number ��a Size '� '`
Located At roe�-- Serial Number �� ���SS"�
Is the assembly installed i 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 aY'`��psid Held at � psid Opened at Opened at Held at
Initial Test Closed Tightf��� Closed Tight psid psid psid
Leaked'i�I Leakedl I Did not open I Did not open � I Leakedl ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i�;�, �Closed Tight�� I psid psid psid
Test gauge used: Make/Model �/��/C/(,�S SN: ��/3/�Sd
Date Tested for Accuracy: �/��•- /�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �(�E'YS/�'� Firm Address 0 ,�'0 --�- �� ' efCjD
Certified Tester(pr:nt)�(�ti,�eS �Y�F� Certified Tester(signature
Firm Phone#���� 6�'�� �j�Cert.Tester No. J�D 9°,�6��D 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