2015_0825 IRRIGATION � DOMESTIC FIRELINE
The following farm 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 LD. # 0570040
(Customer)
MAILING ADDRESS: �
CONTACT PERSON/PHONE: — �'j 7a�- ` -
LOCATION OF SERVICE: �
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
I�ilj,educed Pressure Principle �Reduced Pressure Principle-Detector
+�Double Check Valve �� I Double Check-Detectar
'�IPressureVacuumBreaker !�Spill-Resistant Pressure Vacuum Breaker
Manufacturer ���CC� Model Number ;��� Size ��__
Located At 1 ���'C''_�/ � �,�. C�►�Vl� Serial Number �'�'�g�d]('� 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 �� ps Held at�.�ps' Opened at Opened at Held at
Initial Test Closed Tightl� Closed Tight �� psid psid psid
Leaked. 1 LeakedC Did not open 1 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 ClosedTight����_J ClosedTight�� I psid psid psid
Test gauge used: Make/Model W�1�i��i h�/�� SN: �,� I(�� (9��
Date Tested for Accuracy: � �- l�
Remarks:
The above is certified to be true at the time of testing.
Firm Name�j�51��RC_.►`t ICt���>Firm Address_�rK�,�9_�{r l�Lt�' i��'?JrC��f
Certified Tester(pr;nt) � ertified Tester(signature) �
Firm Phone# r�r.����' 1�I FS Cert.Tester No. ��aC'j('lo�]d�f Date ���'"��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy