2015-1016 IRRIGATIOfd DOMESTIC RRELINE �
The following form must be completed fvr each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIflVTENA9�ICE REPORT'
NAME OF PWS: CfTY OF COPPELL PWS LD. #0570040
(Customer}
MAILING ADDRES�: �it�zK►-,-� �r�S,�.�l��1�.e, ���/v� �iCL� � 76 G�)
CONTACT PERSON/PHONE: /Z���',��� ���. �-��_ 8���
LOCATION OF S�RVICE:_1/�b ExE" c.0 i i�
The backflow prevention assembly detailed below has been tesced and maintained as required by
commission regulations and is certified to be operating weithin acceptable parameters.
TYPE OF ASSE.IMBLY
1Reduced Pressure Principle Re�d ced Pressure Principle-Detector �
;Double Check Va1ve v�Souble Check-Detector
�PressureVacuumBreaker -?Spill-Resistant Pressure Vacuum Breaker
Manufacturer_�� Model Number �4 l� ��G�� Size c�
Locat� At S� ��s,,..� ._� (/e`.�� Serial Number�/3�.$�(
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 1��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Daubie Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at 3'2 psi Held at�`�psid Opened at Upeneci at Held at
Initial Test Closed Tighf . Closed Tight ' psid psid psid
Leaked; � Leaked�..i Did not open . ' Qid not open I Leaked. i
Repairs/
Materials
Used
Held at psid Held at _psid
Test After — (7pened at Opened at Held at
Repair ClosedTight ClosedTight( ! psyd pSed psid
Test gauge used: Make/Model �� ��,� SN: U 7 0�j n N�'Y
Date Tested for A�ccuracy: ���v -/.�
Remarks: �
The above is certif ed to be true at the time of testang.
Firm Name_�C�� �«. �r��_Firm Address_ Pa�. 7T97 fiti..�C, � �,�L�'
d-
Certified Tester(pri nt)�.,�.���, �,,,.���,�rtified Tester(signature) ��'�^-.--�`-�'�'
Firm Phone#_O �' S3'd -2zi�� Cert.Tester No.�d�� �6j-�� Date / �� /G•/S
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
Whife-City Copy Yellow-C�astamer Cagy Pink-Tester's GoPY