2015-0714 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 I.D. #0570040
(Customer) �
MAILING ADDRESS: 3S � (: �L��w-o-c�+� D,2. Ga��<<.c, , j x �S Dl`�
CONTACT PERSON/PHONE: J o�t� � 9�Z' 2 0� � y (�B(�
LOCATION OF SERVICE: �s I ��c��y� �. ,
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 Rf duced Pressure Principle IReduced Pressure Principle-Detector
I�YDouble Check Valve I Double Check-Detector
�1PressureVacuumBreaker 1:�Spill-Resistant Pressure Vacuum Breaker �
Manufacturer W � �1��w s Model Number �S 8 Size � 4�
Located At ��-►-�`� �w-�,� �'`/ ✓11,t�rEl2 Serial Number �`���25�
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? �G 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 � �8 psid Held at 2�z psid Opened at Opened at Held at
InitialTest ClosedTight.�Y ClosedTight '�-I� psid psid psid
Leakedl ! Leakedf I Did not open `� Did not open � 1 Leaked'����
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� I Closed Tight I��� psid psid psid
Test gauge used: Make/Model ���µb"L^� $Y5 SN: D 538�(QS��
Date Tested for Accuracy: I�-S" ��
Remarks:
The above is certified to be true at the time of testing.
FirmName ��A qcf�vv I.�kGuz��o+-� Firm Address i'�jl 1,4�nky D�.�'�O3 ��,�.o��Ye�s,Tje �S�a �]
Certified Tester(print)�S�P�ti lL �Z�+��� Certified Tester(signature)_ �'`'�1�'�
Firm Phone# ��2 "Zy�Z-ZZZ�1 Cert. Tester No. I��`���3�� Date 1' ��"�-�
* 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