2015_0925 (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 LD. #0570040
(Customer)
MAILING ADDRESS: I 3�� ��'an I�'" �i r
CONTACT PERSON/PHONE: �Dui e C.iC�S Z� ' G— d O
LOCATION OF SERVICE: �d� �� e'o' �� S t�''�/+C.e C�{e,F"
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
f ��Reduced Pressure Principle � JReduced Pressure Principle-Detector
+�➢oubleCheckValve ❑Double Check-Detector
'1PressureVacuumBreaker CSpill-Resistant Pressure Vaeuum Breaker
�^ �r- r l
Manufacturer 1—�4� �-a Model Number �� v Size Z
Located At � � � �� S� Serial Number �'t �����
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 ��2 psid Held at ��� psid Opened at Opened at Held at
Initial Test Closed Tighti'�10 Closed Tight 7� psid psid psid
Leakedf 1 Leakedl I Did not open ' I Did not open C�] Leaked'���
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight L-� Closed Tight f� psid psid psid
Test gauge used: Make/Model �r"��'�LL' �� + Z� �� SN� Z����
Date Tested for Accuracy: � �� �S�
Remarks:
The above is certified to be true at the time of testing.
FirmName�(��'I` �"S� Firm Address i3b� �+�a 1� �t►'�
` � � �.
Certified Tester(pr'snt) 1.,Jb�V ld � � 1� Certified Tester(signature)
Firm Phone# z� l���L`�d�� Cert.Tester No. ����?5� 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