2015-0709 (3) IRRIGATION " 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: �/Kf P�/r G04 F 9G''si��i��./.q o��S /!7A/ yG Z�/D
CONTACT PERSON/PHONE: �c� T r��T��tf %9 Z — 6 / G ? 5�/
LOCATION OF SERVICE: owT�1/NF/C Srv/�C ,Sb e� I��[P orT pKw ?SO/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
��1R duced Pressure Principle -IReduced Pressure Principle-Detector
oubleCheckValve �JDouble Check-Detector
7PressureVacuumBreaker � ISpill-Resistant Pressure Vacuum Breaker
Manufacturer (/[//�'�� Model Number Oa7 r�� Q T Size Z ��
Located At (N• 1�D� O� B�/G D/k��� �T+'�GTSerial Number l � �3 3 1
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �P 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 2 '�psid Held at 1�� psid Opened at Opened at Held at
Initial Test Closed Tightf/ Closed Tight F'l� psid psid psid
Leaked'���1 Leaked'� I Did not open ' I Did not open I I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl�__ ClosedTight����l psid psid psid
Test gauge used: Make/Model �p0�<O �T��—v SN: � 9 �y �3 7 y
Date Tested for Accuracy: � � 9� Zo�r'�
Remarks:
The above is certified to be true at the time of testing.
FirmName 7f{C- J�jl�Tf�S . ��'''L Firm Address�S/ /09Tysr //�icli�-yrbi✓, 7�� 7Gb/�
Cerrified Tester(pr�r�t) �v�4� ��*�. Certified Tester(signature)
Firm Phone# ��/�J 6`�d' zL Z 3 Cert.Tester No. ��00/3l DO Date `7"" �— Z���
* 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