2015-0901 IRRIGATION V 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 I.D. #0570040
(Customer)
MAILING ADDRESS: I� 2�! N� D/�L G/�S P�C�iy ,d/�G G/�J'S 7�.'', 7y Z�l/
CONTACT PERSON/PHONE: S/�L v/�lJv/Z 4/4//�/� �2/�}~�'��j - 5�
LOCATION OF SERVICE: G3_rj' ��/��g'/°G2T f�l'�'�S�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certifled to be operating within acceptable parameters.
TYPE OF ASSEMBLY
-]Reduced Pressure Principle -7Reduced Pressure Principle-Detector
�ouble Check Valve -1 Double Check-Detectar
::1PressureVacuumBreaker lSpi11-Resistant Pressure Vacuum Breaker
Manufacturer W`�-K�/ZS Model Number �J�U�L j Size �2
Located At �lj/ t��GUIL�g O.� Q.Y/�1��� Serial Number ���2 7��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
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 �. 7 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight P� psid psid psid
Leaked��] Leaked�l Did not open I I Did not open I I Leaked��l
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight��1 Closed Tight f '�� psid psid psid
Test gauge used:Make/Model �/�- G(�ES I SN: � J���� �
Date Tested for Accuracy: �-�J� LpS J
Remarks:
The above is certified to be true at the time of testing. �.x �����
Firm Name �-/y�� r�� Firm Address y3 75��//��•4''�!/�CS/.. /�p, 4�/PTH
Certified Tester(pri nt) pCs/g� 1�'S�'�Certified Tester(signature) ,(� 1LOtil/���d�/�/
Firm Phone# ��/_ v `�' L-��� Cert.Tester No.Q�aab��7�� Date �� ��
* 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