2015_1013 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: I.3D� I�OC'fl A1�L�le �Iz� �PPEu-�k
CONTACT PERSON/PHONE: LOIt�S M IkGf�S 2 I�' �i(o'"$q�U
LOCATION OF SERVICE: (Q/S �7`�.3�yfFRl7 �RI�'G--' Ct�'I'TD/uW��'p K �IEM
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�Reduced Pressure Principle �Reduced Pressure Principle-Detector
I�'���Double Check Valve �Double Check-Detector
CPressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker
���5 Model Number �O� -�� Z� /
Manufacturer a� Size
Located At�QpN i OF �C;NbOI. �/�1� Serial Number �53�5
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 �r�7 psid Held at � � Z psid Opened at Opened at Held at
InitialTest ClosedTight���� ClosedTight�l psid psid psid
Leaked�] Leakedf I Did not open -�1 Did not open .1 Leaked'� ����
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Neld at
Repair Closed Tight I 7 Closed Tight I psid psid psid
Test gauge used: Make/Modell�M 4C�� 2� "TK SN: �S�Qt�[�
Date Tested for Accuracy: �Il� l�
Remarks:
The above is certified to be true at the time of testing.
FirmName���-'�� �—S� Firm Address ����'`��n �f1'�r^, �P(����
Certified Tester(�rint}��U�� ���P� Certified Tester(signature) �
Firm Phone# �������`�Sd� Cert Tester No���� 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