2015-0709 IRRIGATION �O DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS: tJX� CA/T O E, �L 3r 15�p�s��✓A o/i� /�,�/ yL 2 yD
CONTACT PERSON/PHONE: �i K�s r ,�r[ rE�s
LOCATION OF SERVICE: Cv.✓T�iNE� TO�c� ,SOO fRte � �iewy, p,sp� 9
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
���Reduced Pressure Principle �IReduced Pressure Principle-Detector
i�uble Check Valve ]Double Check-Detector
❑Pressure VacuumBreaker I �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �/l/��� Model Number 00'7 /�'1/ GQ T Size Z ��
Located At � ��.�J� o/= 8v�<o�� � .STke7" Serial Number /� 7 S��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? i/�,S �
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at �'� psid Held at Z� � psid Opened at Opened at Held at
Initial Test Closed Tightf� Closed Tight P� psid psid psid
Leaked'� 1 Leaked��� I Did not open I I Did not open �� Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight'� I ClosedTight�1 psid psid psid
Test gauge used: Make/Model /`rPOI/O �T/�5v sN: 0 9 i y z 3 '� y
Date TestedforAccuracy: 7— 9" zo�s
Remarks:
The above is certified to be true at the time of testing. �
FirmName / /�G- �ySTf�s, x^�L Firm Address 7S/ /09'��T �x��yTb� � '7(00 /�
Certified Tester(prir,t) ��/p�✓ ��''� Certified Tester(signature)
Firm Phone#�8»�6yd' z L- z3 Cert.Tester No. �1'0��3� d Date 7"9' Z a�S'
* 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