2015-1016 (2) IRRlGATION DOMESTIC FIRELINE v
The fallowing 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 A1VD 1VIAI�fTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. #057004Q
(Gustomer)
MAILING ADDRESS: vv�.,.o,� �ivv / p L, � 6 o I)
CONTACT PERSONfPHONE: o _ ,
LOCATION OF SERViCE:_///a Eec f _vt,�,!
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceplable parameiers.
TYPE OF ASSEMBLY
+Reduced Pressure Principle Reduced Pressure Principle-Detector �
i�ouble Gheck Valve : !Double Check-Detector
�-�'PressureVacuumBreaker -,;Spill-Resistant Pressure Vacuum Breaker
Manufacturer �`"�`- ModelNumber �o'I�� Size ���
Located At S�� cv-�,,�� � � Serial Number � 88 6`�
Is the assembly installed in accordance with manufacturer recommendations and./or loca( codes? �
Reduced Pressure Princi 1e 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
1'nitial Test Closed Tighti+-! Closed Tight trl� psid psid psid
Leaked: ': Leaked.i Did not open ` ' Did not open ' Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Openeci at Opened at He1d at
Repair Closed Tight_i Closed Tight ' ps�d Ps�d psid
Test gauge used: MakefModel__ ��L-Y- �� � SN:_ O 70 9 0���
Date Tested for Accuracy: -�'1� - t�
Remarks:
The above is certified to lae true at the time of testing.
Firm Name_�G�,w,,,_ �� �y�5 Firm Address �-� So-yt, ��j� �:t/�, '�. �.�'/��
Certified Tester(print)�s,,rn�'����u�ertified Tester(signature) � �rry�
4
Firm Phone#_���' s�o-��� Cert.Tester No.��'a"0� �'�S 7 Date � ° � �b'��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Custamer Copy Pink-Tester's Gopy