2015-1016 (9) IRRIGATION DOMESTIC FIRELINE �
The followi�g form must be completed For each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOVN PREVENTION ASSEMBLY TEST AND MAIiVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer}
MAILING ADDRESS: vr>S ���/p,t� , ��o/( ,
CONTACT PERSON/PHONE: ' � �. v t—
LOCATION OF SERVICE: //// ��r� c�,��,,.�
The backflow prevention assembly detailed below has been tested and maintained as required hy
commission regulations and is certified to be operating within acceptabde pararrteters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle -'Reduced Pressure Principle-Detector �
:Double Check Valve �ouble Check-Detector
�Pressure Vacuum Breaker -";Spill-Resistant Pressure Vacuum Break.er
Manufacturer �� Mode1 Number �v 9 D�� Size a
Located At G- f�St �� ��Q� Serial Number (� G/' ��/�
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[nlet Check Va1ve
1 st Check 2nd Check
Held at Z�� psid Held at�, I psid Opened at_ _ Qpened at_. Held at
Initia(Test Closed Tight� Closed Tight +�!� psid psid psid
Lea}ced ; Leaked I id not open J Did not open Leaked
Repairs/
Materials
Used
Held at �asid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight : Closed Tight ' psid psid psid
Test gauge used: Make/Madel Gvvt�/e.+�.-, �� S' �N: �'7��p���
Date Tested for Accuracy: �-/U �/,S�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �r�� �� 5 Firm Address �� —SSt� _. ZZg�7
Certified Tester(pri nt),����?,,,,,�„�ertified Tester(signature)_i��-�.�C-�Gc.�-.�-y.--__
—����--
Firm Phone#_O b�� 5 S� _2,z y'� Cert.Tester No.I��on� �/3'� Date /v- /�-�.j�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Y�llc�w-Custorner Copy Pink-Tester's Gopy