2015_0925 IRRIGATION C 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) c�
MAILING ADDRESS: � 3 �� �ran IQ►'' Cir e��� �s� ( 1
CONTACT PERSON/PHONE:I-bui ' ac:�A Z� - (v �- D40
LOCATION OF SERVICE: Z�o t� ��►-��5 ,��^n V � pac��/
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
-]Reduced Pressure Principle f-Reduced Pressure Principle-Detector
?4�ouble Check Valve I 'Double Check-Detector
�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
r t�
Manufacturer�Pi�C-v Model Number �� Size � �L
Located At Fr-Ol'1'�O� '����• �%4� ��� Serial Number � 2� 3� Z
Is th�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��d psid Held at �r Z psid Opened at Opened at Held at
Initial Test Closed Tightl�- Closed Tight �' psid psid psid
Leakedl I Leaked'�.� Did not open �� I Did not open I I Leakedi
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight L7 Closed Tight f 1 psid psid psid
Test gauge used: Make/Model ��m��-0 �� ��� SN: �5$O C�
Date Tested for Accuracy: ���ZS �15
Remarks:
The above is certified to be true at the time of testing.
Firm Name�(���' 1-S � Firm Address ���� �"al'1�1Qf�' �1►''
.
Certified Tester(prsnt)�C�1��d �C�1�°v'� Certified Tester(signature) � �
Firm Phone# ��'"�����d�� Cert.Tester No. L���o� Date � Z� �S�
* 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