2015-0709 (2) IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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 LD. # 0570040
(Customer) ^
MAILING ADDRESS: ✓vKt �Fa1 T GOO E 9G 'T..t�O�A�✓��o%s ,y�,� ,�� zy0
CONTACT PERSON/PHONE: k x�t T A./TL�
LOCATION OF SERVICE: o�vr�iNtic JTa�F Sov Fx«po�rT PKui 7J'OJ�J'
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
�R duced Pressure Principle -1Reduced Pressure Principle-Detector
����oubleCheckValve -]Double Check-Detectar
'� IPressureVacuumBreaker 1Spil1-Resistant Pressure Vacuum Breaker
Manufacturer /¢1TS Model Number po 7 m i q T Size
2 ~
Located At /✓• -S�D� OF �jvi�Di+� �y JT�tqSerial Number / ZG d ,3 9
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �+�5
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 l.•-�psid Held at Z'�psid Opened at Opened at Held at
Initial Test Closed Tightl� Closed Tight f✓ psid psid psid
Leakedf��� Leaked�1 Did not open f'�� Did not open I '� Leaked'�� I
Repairs/ '
Materials �
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight _! ClosedTight I 1� psid psid psid
Test gauge used: Make/Model /����`� �Tk�� SN: � % � y L.3 7 y
Date TestedforAccuracy: 7- 9" ZOl.S—'
Remarks:
The above is certified to be true at the time of testing.
Firm Name TI��- �3 Tfw+1 � �NL Firm A ddress 75/ !09 T��r �.t�i�.y�aN� TiZ ?LO/1
Certified Tester(pr�nt) �Uw� �'�'i- Certified Tester(signature) �
Firm Phone# ��I7�Gyb - z L z3 Cert.Tester No. B�OD/3/O p Date 7' 9' Zo�.r
* 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