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 I.D. #0570040
(Customer)
MAILINGADDRESS: �I�J3D P�dS� �� • T,��vU 4.S �X.
CONTACT PERSON/PHONE: v�� � �/ ' ds 2- —
LOCATION OF SERVICE: 2 Ycs 4 �. ✓. �� �� �
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
�Reduced Pressure Principle �1Reduced Pressure Principle-Detector
I Double Check Valve �Double Check-Detector
❑PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
w �.,F o 9 � 2 QTsize ~
Manufacturer U S Model Number � 2
Located At /Vo✓� w� - w�-✓t�.u�.St Serial Number '0�d� g� �
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 �•0 Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leakedl �� Leakedl��'� Did not open I I Did not open � I Leakedi��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�_7 Closed Tight_ I psid psid psid
Test gauge used: Make/Model V" w�5 + �I� ' � 1 � SN: ��` 2�s
Date Tested for Accuracy: S ��-� � Z 0 I S
Remarks:
The above is certified to be true at the time of testing.
FirmName 1'i0w�u� KG�t �I�g . Firm Address � ILa �o • ` `� �`` ��
Certified Tester(pr:nt) ( ��t � • I� Certified Tester(signature) � ��
Firm Phone# S���ZZ-Z--��7 7 Cert.Tester No. 8� ��1�2- Date �'' Z'T' ��
* 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