2015-1016 (7) IRRIGATION DOMESTIC Y� FfRELIhfE
The following form must be completed fiir each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIP�iTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #U570040
(Custamer)
MAILING ADDRESS: � �vo ..Snc /�. �fe, �by �; -� 6oJ
COI�fTACT PERSON/PHOIYE: d�„� �'n�a� ' /7� 37�_ �c�y�
LOCATIO?� OF SERVICE: //%/ ,,�?'��
The backflow prevention assembly detailed below�has been tested and aa�aintained as reyuired by
commission regulations and�s certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle Reduced Pressure Principle-Detector �
�ouble Check Valve ._ D�ouble Check-Detectar
�PressureVacuumBreaker -1Spi11-Resistant Pressure�acuum Breaker
Manufacturer //(JR�� Model Number__ @d�{2� j Size Z��
Located At �� � �( � ��Serial Number Z/qG0
�
Is the assembly installed in accordance with manufacturer recommendations and/or iocal codes?
RedUced Pressure Princi le Assembf Pressure Vacuum Breaker
Double Check Valve Assembly
ReliefVatve Air Inlet Check Valve
1 st Check 2nd Check
He1d at��psid Held at�� g psid (7pened at.____ Opened at Held at
Initial Test Closed Tight✓ Closed Tighk f psid psid psid
Leaked: Leaked' ' Did not open nid not open ! Lcaked:
Repairs/
Materials
Used
Held at psid Held at psid
Test After (�ened ai Opened at Held at
Repair Closed Tight':1 Closed Tight' p$id psyd psid
Test gauge used:Make�Model G✓.�1�-�•� �(�� ��: � 7 a g v���
Date Tested for A�ccuracy: (-/G� - /S
Remarks:
The above is certified to be true ai the time of testing.
FirmiVame �i C�w•-� 1' -� Fircn Address pa
� �r° _�___�_?eI'7 �� /'� 7S,!��
Certified Tester(pri nt) �fEe ��✓ Cer[ified Tester(signature} �� �a��
Firm Phane#_ �� - S'S 0-Z2�) Czrt.Tester No.��t��l SlI Date /o /���5
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellovv-Customer Copy Pink-Tester's Copy