2015-0709 (4) 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer)
' MAILING ADDRESS: ✓UKE ���olTy �Gmo E. �� �r�.,o•A•��po/•s� �,� yG 2ya
CONTACT PERSON/PHONE: C`i��� T A-/�f.cs
LOCATION OFSERVICE: Conir/�liN�i .5�n� ,TtJO F�«PoK-r' PK�e-y ?cf0/ �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
:�Reduced Pressure Principle f-lReduced Pressure Principle-Detector
�ouble Check Valve -�Double Check-Detector
-]PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer `!(/ i¢fTs Model Number �� 71Y1/ �t T� Size Z-��
Located At /1� ��d f Of Bvr��rn.� 6y .�TrP�T Serial Number / z .S 9�3
Is the assembly installed in accardance with manufacturer recommendations and/or local codes? y"� 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 �• Z psid Held at �� 7 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight !� psid psid psid
Leakedl � Leaked�� I Did not open I � Did not open I � Leakedf�I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I�i Closed Tight �I psid psid psid
Test gauge used: Make/Model /7P���� ` T��v SN: D � �y 2,3 7 y
Date Tested for Accuracy: '�' ��- �� S
Remarks:
The above is certified to be true at the time of testing.
FirmName �G- Jy�Tfiy►�� Z�`L Firm Address 7S/ IDa�'sT A,-�n,g�-o,✓, nj 7L0�1
,
Certified Tester(pr:�nt) �vr1� ��� Certified Tester(signature) �i1
Firm Phone# Cd'�7�b yb� Z Z Z 3 Cert.Tester No. ,�1°OO/3/ O Date �� 9' �-�
* 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