2015_1013 (2) 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: �38� �t��oLE2 C-'s�-• C�PP�LL�x
CONTACT PERSON/PHONE: nva S R(.A}S Z r 4 �(g(.�- D��
LOCATION OF SERVICE: Fei/.S �Yl i+V f�R,D 1�R��F c'o�r-ra�! � QoA �'��1
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
���1Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
'f�.DoubleCheckValve ❑Double Check-Detector
�PressureVacuumBreaker I �Spill-Resistant Pressure Vacuum Breaker
r �� �
Manufacturer UvQ�S Model Number ���/n � � Size %Z-�
Located At �eb�'� O� SC,HOUL �'`���K Serial Number Z� ���
Is the assembly installed in accordance with manufacturer recommendations and/ar 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 ��7- psid Held at � �`� psid Opened at Opened at Held at
Initial Test Closed Tight���� Closed Tight'S4 psid psid psid
Leaked� 1 Leakedl���'� � Did not open I Did not open ��� I Leaked� i
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight C�� ClosedTight f.l psid psid psid
Test gauge used: Make/Model�b�0�-� �d ' ��b 'T�L' SN: zS�C�C�t�
Date Tested for Accuracy: �1�O �S�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �P�C��- �" �� Firm Address ��� W I�N �/Z ��� � �I �,
Certified Tester(pr:nt�Q��C'� �ClI /�/ Certified Tester(signature) �� �
Firm Phone# �7 r `tq�' g6�U Cert.Tester No.�J�Ol.vlv�� 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