2015_0821 IRRIGATION� DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated origina]
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 LD. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: I'�-�-3 G1.� 5�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�r7Reduced Pressure Principle [JReduced Pressure Principle-Detector
�RoubleCheckValve I ,'Double Check-Detector
�1PressureVacuumBreaker ' ISpill-Resistant Pressure Vacuum Breaker
1
Manufacturer �-� Model Number �j_�M 2�� Size �Z
Located At �/� c;G.�' '��' �a� Serial Number �o`��`�
Is the assembly installed in accardance with manufacturer recommendations andlor local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
Held at�psid Held at � '� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leakedl� Leakedl I Did not open ���� I Did not open � I Leaked�� ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight���� I Closed Tight f! psid psid psid
Test gauge used:Make/Model ��� ��"`1 ��''� SN: � 3 ( 2-2 D G �S
Date Tested for Accuracy: 5 � � f 5
Remarks:_�6,��y
The above is certified to be true at the time of testing.
Firm Name ht--�i �` � l '�-� Firm Address 0 �� � �''�'� ��
Certified Tester(print) �G,v�� C'���•(i"�'�' Certified Tester(signature)
Firm Phone# ��� � �� �-2�� Cert.Tester No.��D��3`� Date �� �-l—�3�
* 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