2015-1016 (3) IRRIGATION DOMESTtC FIRELiNE !�
The following form must be completed fi�r each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes;
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIPVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS [.D. #n57U04Q
(Customer)
MAILING ADDRBSS: /�IlY���v �v'�Sn� ��rl4S ,�YZ �'�� fvt� /CL � 7/�o l 1
CONTACT PERSON/PHONE: �vd.�,�j��'�.�,�, ,�.� �� �_ 3�� - 8�c�rc
LOGATION OF SERVICE: f//U �'e� � ,,�,�;L���—�
The backflow prevention assembly detailed beloov�has been tested and m�intained as required by
commission regulations and is certified to be aperating within acceptabie parameters.
TYPE OF ASSEMBLY
i Reduced I'ressure Principle uced Pressure Principle-Detector �
1 Dou�le Check Valve
ouble Che�:ic-Detector
'-7PressureVacuumBreaker -°Spill-Resistanr Pressure Vacuum Breaker
Manufacturer_ /c�a� Model Number ��`7�it-�dR-- ��'
Size
Located At� �,. �C,�,��,Q� Serial Number //�� U �
Is the assembly installed in accordanee with manufacturer recommendations and/or Ioeal codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Reiief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at 3' �psid Held at 2'psid Opened at __ Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid P��d
Leaked' ; Leaked ; Did not open ' Did not open I��I Leaked
Repairs!
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i i Closed Tight: i ps�d psad psid
Test gauge used: Make/Model L.��[�-�-" T�j SN. p 7� 9�t�y�
Date Tested for Accuraey: - U -/.�
Remarks:
T'he above is certified to be true at the time of testing.
Firm Name_fi E'i�oLr� �x.� �Vd� Firm Address p� L�v�-�.. �7�� LeJ� % 75/-(��
Certified Tester(print)�� „D;� Certified Tester(signature) ��
Firm Phone#_��' SJ�-2� Cert.Tester No. ��� �/�'"'� Date tG - /�-/�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-C'ity Copy Yellow-Customer Copy Pink-Tester's Copy