2015_0802 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:
CONTACT PERSON/PHONE: G V���
LOCATION OF SERVICE: 7_ (��jvf �'��,�o�
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
� Ilj,�duced Pressure Principle C��Reduced Pressure Principle-Detector
4��oubleCheckValve �Double Check-Detectar
'lPressureVacuumBreaker �ISpill-Resistant Pressure Vacuum Breaker
Manufacturer I�eVJCJ Model Number �0 Size ��,
Located At��Q�'�Q1r Serial Number ��� I�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 \ , g id Held at�p Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight I psid psid psid
Leaked!�1 Leaked' I Did not open ��� Did not open �l Leaked'�� ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight-J Closed Tight❑ psid psid psid
Test gauge used: Make/Model(�b�t� L11��0V'��C.S V SN: u3�(�U(�(eW
Date Tested for Accuracy: � �'q '�0\`
Remarks: �T
The above is certified to be true at the time of tesring.
Firm Name L.val�j,L�. 'S,N�,�V��9n Firm Address S ' � �����
Certified Tester(print) CWr� ���y�Certified Tester(signature)
Firm Phone#�����(��_Cert.Tester No. �'uV���� 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