2015_1215 (2) IRRIGATION_ i� 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$�h�y ��,,�` �Q� C C��..�e� —7 O/4
CONTACT PERSON/PHONE: �'i�Z . �l�eZ . ` <o O O
LOCATION OF SERVICE: /�/,!O ,G. 4,,.� 11f��,
The backflow prevenrion assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
i �Reduced Pressure Principle I Reduced Pressure Principle-Detector
�ouble Check Valve '-I Double Check-Detector
� IPressurcVacuumBreaker � 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �Q,�� Model Number 8S0 Size 2, O ��
Located At�r-eQ,,` �Q�';��. ,(�x e rn��er Serial Number 3 3 o O�
Is the assembly.installed in accordance with manufacturer recommendations and/or local codes? [.1a s
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at psid Held at 2. I psid Opened at Opened at Held at
lnitial Test Closed Tight! Closed Tight I✓ psid psid psid
Leaked�h" Leaked' I Did not open I 1 Did not open Leaked'
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight J Closed Tight ! psid psid psid
Test gauge used: Make/Model �i/�e;..s T�$ SN: O'72'7/�9 �
Date Tested for Accuracy: /�� zOLS
Remarks: NQ�Is 1t.t cL�e�c
The above is certified to be true at the time of testin�.
FirmNameD��e.-s:-�.�a/ F� Fraf Firm Address�q�J�,-�,/,,,�,u t-'�J -�C �G//Z
Certified Tester(pr�r;r),,,$e�,,, �i J��,�,Certified Tester(signature) � �
Firm Phone# $'/�. �3�( . 4 �09 Cert.Tester No. �O/� D�l Z Date .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