2015-0917 IRRIGATION�_ DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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 I.D. # 0570040
(Customer) ` �
MAILING ADDRESS: � I�� �J u., �
CONTACT PERSON/PHONE: # — — �
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
❑Reduced Pressure Principle �Reduced Pressure Principle-Detector
,'�4,pouble Check V alve -1 Double Check-Detector
lPressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer ��pGQ Model Number �� Size�_
Located At ��GAPX �Vl'�' Serial Number 1'I� ��j�—f'q�_
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 Opened at Held at
Initial Test Closed Tightf� Closed Tight� psid psid psid
Leaked.] Leakedl J Did not open '��i Did not open � '�� Leakedf��'��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight��] Closed Tight CI psid psid psid
Test gauge used: Make/Mode � � ` SN: �j��
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
Firm Name����N f���iC�Firm Address f'�01 �x 17�����(�g� /��(0003
��,L�, U
Certified Tester(pr�nt) � ertified Tester(signat
Firm Phone#�`��r,�I—Y�� Cert.Tester No. Date ! l
* 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