2015_0220 IRRIGATION DOMESTIC (` FIRELINE
The following fortn 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: �a 5 5 ��e/IPfL S���i K s /�C�c�� s�;.�
CONTACT PERSON/PHONE: � ���y S���h `r 7 a — 3 �/� 3 rz�
LOCATION OF SERVICE: :��l� Gl/.- 5.9 w�l� � r�. Tt
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
�1Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
Q�DoubleCheckValve C IDouble Check-Detector
�PressureVacuumBreaker JSpill-Resistant Pressure Vacuum Breaker
7 fl "
Manufacturer /'�l�� G Model Number � Size �
Located At
/'����'�- Serial Number �� �l��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�psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight� psid psid psid
Leaked�� 1 Leaked. 1 Did not open I ' Did not open ��� I Leaked'i I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight�_l ClosedTight .I psid psid psid
Test gauge used: Make/Model G d�h���o � v�'b° SN: D G U y�T�1�
, Date Tested far Accuracy: 3 -� �" � �
Remarks:
The above is certified to be true at the time of testing. �
Firm Name �`'����'`' � « t Firm Address ���'���'� 7� � ��k�' 7� �����
Certified Tester(pr:nt) �' �f c �'�' ��'�`� s Certified Tester(signature)
Firm Phone# �D d�5 5�- o�� �' � Cert.Tester No./3/��ao° 1�� Date Z �� �/�
* 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