2015_0908 IRRIGATION � DOMESTIC FIRELINE
The following farm must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer)
MAILING ADDRESS: � ` `
CONTACT PERSON/PHONE: p y� f�J<<� q- (— (�`
LOCATION OF SERVICE:
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
�I duced Pressure Principle �Reduced Pressure Principle-Detector
i�ouble Check Valve i_:_Double Check-Detector
C IPressure VacuumBreaker ' I Spill-Resistant Pressure Vacuum Breaker
Manufacturer W fl�� Model Number LF dd`']Mo�� Size "d��_
Located At � -1,�� f '}-h��-'`c�L,Jl�erial Number �a-]��
/
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��p,qfd Held at��psi Opened at Opened at Held at
Initial Test Closed Tight•� Closed Tight I��� psid psid psid
Leakedl I Leaked�1 Did not open '� Did not open �1 Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C Closed Tight' I psid psid psid
Test gauge used: Make/Model�'t� DC.i S���Fj SN: o��ol�h9
Date Tested for Accuracy: � �'�a���
Remarks: . �/ �� �y� ��j�
The above is certified to be true at the time of testing.
FirmName��{�jPrC�Ct'IC�c1��V�i.4�r'Firm Address CU�X�,����P wSV'}�� X�7��
Certified Tester(pr:nt)� � �Certified Tester(signature) �
Firm Phone#����(�g���$�i Cert.Tester No.��Q���j� Date ��-�-�5
* 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