2015-0901 (2) IRRIGATION DOMESTIC V FIRELINE
The following farm must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: � /I/ A� �K�i , /,�/qL�� `T�Y, 7Sg�/
CONTACT PERSON/PH NE: �1/ 2 /� l�'-' ` y
LOCATION OF SERVICE: �"P � �w
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
-7Reduced Pressure Principle I Reduced Pressure Principle-Detector
� �oubleCheckValve I IDouble Check-Detector
-�PressureVacuumBreaker f��Spill-ResistantPressure Vacuum Breaker
Manufacturer W�L���''s Model Number ���X`r Size
2 �
Located At i ti G/�arti� �3 a�'�3 yrl��l� Serial Number -e � z� 7��
Is the assembly installed in accordance with manufacturer recommendations andlor 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 2•0 psid Held at ��psid Opened at Opened at Held at
Initial Test Closed Tight3Q Closed Tight � psid psid psid
Leaked.�1 Leakedl I Did not open I I Did not open I I Leaked�1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� ] Closed Tight f 1 psid psid psid
Test gauge used: Make/Model h9�Q-�6� SN: �J'�« �9
Date Tested for Accuracy: � '"���/�S�
Remarks:
The above is certified to be true at the rime of testing.
�C, 7G�6S
FirmName ���� ��C/" Firm Address 37S pif'�ol�A� �; /c���
Certified Tester(print) f�1�� �'��J�'��Certified Tester(signature) �
Firm Phone# Z�I/ �`� L.�h"' Cert.Tester No.���/D�7�3 Date` -� `�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