2015-1030 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:
� L �
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 /����LS
(Customer) '�"�����'-�
MAILING ADDRESS: o�'� o� h/ Dc h i D A/ /�� 1L.1� y�t� ����
CONTACT PERSON/PHONE: L`� +E3� T �a..� �-1-C�°!- —f o�-��as �
LOCATION OFSERVICE: �1�,� ,� ���T�l 'I'�,p /2„_,l�
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
' 1Reduced Pressure Principle 1Reduced Pressure Principle-Detector
�oubleCheckValve -1Double Check-Detector
1 Pressure Vacuum Breaker ��Spill-Resistant Pressure Vacuum Breaker
Manufacturer l,d,� ,1�...S Model Number �� � Size_��
�v�T To �t.[.T�.C`
Located At !�..t- �'or�✓�.�. of ��of'��y Serial Number g�t 1,9,U��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? --S
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 Opened at Held at
Initial Test Closed Tigh� Closed Tight I psid psid psid
��,/�� Leaked��.1 Leaked� Did not open [ '� Did not open ['�� Leaked i�I
Repairs/ �1,�0�`a
Materials c�,��� r�)�
Used �F�
Held at �•� psid Held at l"� psid
Test After Opened at Opened at Held at
��1�7 Repair ClosedTight� ClosedTight� psid psid psid
Test gauge used: Make/Model tbl�.D 1�.0�.5-��r�, ��S-r SN: l c�� q.v—p�.�
Date Tested for Accuracy: �' � �- c�o+�
Remarks:
J�/�,,✓s 1
The above is certified to�be true at the time of testing. �
� �
FirmName `x�.y�S �.����Firm Address l�v � , � ` ,"����
Certified Tester(print)s�� � �c�c•�.� Certified Tester(signatur � --- �� �
Firm Phone#��t a—Q�i�_Cert.Tester No., Oo o Date 1O��p -��
* 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