2015-1016 (4) iRRIGATIt7N D{)MESTIC FIREUNE �/
The following form must be completed fvr each assembly tested. A signed and dateri original
must be sub�nitted to the pub(ic water supplier for recordkeeping purposes:
BACKFLOW PRE VENTION ASSEMBLY TEST AND 14tA,IAiTENANCE REPORT
NAME rJF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: (o� � Q v , y� � 76�/J
CONTACT P�RSON/PHONE: v ��_ —
LOCATION OF SERVICE: ///o E��x�'cyTr r/£
The backflow prevention assembly detailed below has been testecl and maintainc,�c1 as required hy
commission regulations and is certified to be operating within acceptable parameiers.
TYPE OF ASSEMBLY
:-!Reduced Pressure Principle '-:Reduced Pressure Principle-Detector �
�ouble Check Valve 'Double Check-Detector
�-lPressureVacuumBreaker 1Spii1-Resistant Pressure Vacuum Breaker
Manufacturer �/� Model Number 00�!'I�I Size �Y-�
Located At Jl�� C�.�-,,,,,r j�.�.� Serial Number ��98�
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 Vaive
1 st Check 2nd Check
He{d at f Z psid Held at /� � psi (?pened at____ O�ned at Held at
Initia(Test Closed Tight� Closed Tight psid �id psid
Leaked; ' Leaked ' Did not open Did not open ' Leaked `
Repairs/
Materials
Used
Held at psid Held ai psid
Test After Opened at Opene�l at Held at
Repair Closed Tight: ; Closed Tight ' psid psid psid
Test gauge used: Make/Model Gc%,C,�C.-.-, �C�.S' �N; o �o�� �QX
Date Tested for Accuracy: �o-/v-/S`
Remarks:
The above is certified to be true at the tame of testing.
FirmName�_�,z� ��.r��' Firm Address�v�.�,L ��l'7 I.�/e„y�. Ty., �jS-/(�
Certifred Tester(print)�,,,,,,�,Q� l.�ov�ertified Tester(signature)��
Firm Phone# ��''�-_CSJ - Z-z-b'� Cert.Tester No.$F� 6�5-7 Date__�_� �'!
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-C�ity Co�ay Ye!(ow-Customer Copy Pink-T�ster's Gopy