2015-1016 (6) IRRIGATION � DOME5TIC FIRELINE
The following form must be completed fiir each assembly tested. A signed and dated original
must be submitted to the public waker supplier for recordkeeping purposes:
BAiCKFLOW PREVENTION ASSEMBLY TEST AND MAIBYTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. #0570(k�0
(Cuskomer}
MAILING ADDRESS: �i nu,�� �r u f��,��s f�.� �� /Otf ARL �t 76 v/l
CONTACT PERSON/PHONE: J2vo�,� P���►,r,,,,� �,� _ �r - �'��y�
LOCATION OF SERVICE: f//o '�C.�Ct�.�l't t,
The backflow prevention assembly detailed below has been tesied and maintained as required by
commission re,gula#ions and is cerkified to be operating within acceptable paramet�ers.
TYPE OF ASSEMBLY
;Reduced Fressure Principle -'Reduced Pressure Principie-Detector �
�✓n►oubleCheck Valve '.'.Double Check-Detector
-lPressureVacuumBreaker iSpill-Resistant Pressure Vacuum Breaker
Manufacturer ��.$e.c� Model Number �ti.� Y Size 2 w
Located At GcJ� S'1vfL �a��� Serial Number C�f�.���
Is the assembly installed in accordance with manufactwer recommendations and/or local co+des? ,e,v�
Reduced Pressure Princi le Assembt Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air[nlet Check Valve
1 st Check 2nd Check
Held at��U psid Held at 2�`�"psid Opened at_ Opened at Held at
Initiai Test Closed Tight� Closed Tight✓ psiei psid psad
Leaked! ; Leaked i Did not open Did not open Leaked
Repairs/
Materials
Used
Heid at psid Held at psid
Test After Opened at_ Opened at Held at
Repair Closed Tight:' i Ciosed Tight i ! ps�d ps�d psid
Test gauge used: Make/Model W���•— Tb� �' SN: 070�o �S�
Date Tested forAccuracy: ��/v - /�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �C�,,,�, �Y,sz �i�ri j Firm Address �O ��-jG ��7 J,�a.,e., Tx �75'/.(��
Certif ed Tester(pri nt) l�sr, _Certified Tester(signature)_�� ��"���.�
r
Firm Phone#_�U7r�- ,�'SU- zz�'�1 Cert.Tester No. L�e�(�!S� Date /v-/6-/
*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