2015-1016 (10) IRRIGATION DOMESTIC FiRELINE ✓
The following form must be completed fvr each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping pur�wses:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAI�iTENANCE REPOR'I"
NAME OF PWS: CITY UF COPPELL PWS I.D. #U570040
(Customer)
MAILING ADDRESS: �/��e �w (U-v Sn1�%�s_��fDI� ���, � 76°91
CONTACT PERS�N/PHONE: 2�,, p�A��q�/'�NC�r �i�_•�-7� _�sc��_
LOCATION OF SERVICE: //�/ E�.�_,�,}�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be aperating within acceptable parameters.
TYPE OF ASSEiWBLY
'Reduced Pressure Principle 'Reduced Pressure Principle-Detector �
�ouble Check Valve Doubl+e Check-Detector
�-iPressureVacuumBreaker ""Spitt-Resistant Pressure Vacuum Breaker
Manufacturer �� Model Number C d'7 y�� Size�
Located At ��S� �s o'�-- �iw� Serial Number �-I�r�4��I¢x.�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembf Pressure Vacuuro Breaker
Double Check Valve Assembly
ReliefValve Air lnlet Check Valve
1 st Check 2nd Check
Held at /. 2 psid Held at /� T psid (Jpened at __ Opened at_ Held at
Initial Test Closed Tigh� Closed Tight�' psid psid psid
Leaked: } Leaked` 1 id not open ; Did not open ! Leaked �
Repairs/
Materials
Used
Held at psid Held at p�id
Test After Opened ai Operted at Heid at
Repair Closed Tight i Closed T�ght ' ps�d ps�d psid
Test gauge used: Make/Model_ !n/�� Tja S' SN:f>7L�v*��'�'
Date Tested for Accuracy: �-�D- /�S�
Remarks:
The above is certified to be true at the time of testing.
FirmName�� ����-vf Firm Address �a�+�- � -�f� /�/�> "�i ?.���$
Certified Tester(print)����"� �d'J�-✓Certifi�d Tester(sigraature)
Firm Phone# ����,�'a.-� Cert.Tester No. �P�"� l�1 S"7 Date /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