2015_1022 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: � Y'O � C�e v.9
CONTACT PERSON/PHONE:
LOCATION OFSERVICE: �,/y� �"r,u���- �k e
�r-r--�
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 1Reduced Pressure Principle-Detector
�ouble Check Valve -�Double Check-Detector
� I !PressureVacuumBreaker � ISpill-Resistant Pressure Vacuum Breaker
�
Manufacturer P_. 8 Model Number $ 5� Size � y
Located At ��'h� �,v4-i" Serial Number Y�� 02� O ��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? P
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 o�o� psid Held at�* � psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leaked. I Leaked'�. 1 Did not open I I Did not open � I Leakedi I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight�_I Closed Tight�_I psid psid psid
Test gauge used: Make/Model ��,� �� �s SN: ��f3��s �
Date Tested for Accuracy: �^��`l S
Remarks:
The above is certified to be true at the time of testing.
FirmName �U�1��/�� Firm Address 8 �v�-� -S� ��r� c���
Certified Tester(print) �a'�'�'o S CY'c1� Certified Tester(signature)
Firm Phone#Y�� E�� �3�� Cert.TesterNa� ��3��d 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