2015_1028 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: �c�.�,.1�..,' ct o,�•�,r S
LOCATION OF SERVICE: _�� vcti
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
:�1R uced Pressure Principle �Reduced Pressure Principle-Detector
� ouble Check Valve ��Double Check-Detector
!PressureVacuumBreaker � Spill-Resistant Pressure Vacuum Breaker
Manufacturer �Cb«1 Model Number $.S� Size 3/�/"
�
Located At �.✓ Serial Number �1��JD y�
Is the assembly installed in acc dance 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 eld at ��� ps' Opened at Opened at Held at
Initial Test Closed Tightf Closed Tight � psid psid psid
Leakedl I Leakedl � Did not open � Did not open ! � Leaked��� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I '�� Closed Tight I psid psid psid
Test gauge used: Make/Model_�,�p�/0 SN: je�13Z5(�5
Date Tested for Accuracy: y-1 S-�.6 �
Remarks:
The above is certified to b true at the time of testing.
Firm Name � Firm Address S5 ✓
_
Certified Tester(print) Certified Tester(signature)
Firm Phone# ��Z�����Cert.Tester No.__���� Da e �-,�-l5
* 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