2015_1112 IRRIGATION�_ DOMESTIC FIRELINE
The following form must be completed far 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:
CONTACT PERSON/PHONE: !�1 w+�A-/L A � G� � �1 tT�S
LOCATION OF SERVICE: /Y �
The backflow prevention assembly detailed below has been t sted and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
-iReduced Pressure Principle �Reduced Pressure Principle-Detector
�oubleCheckValve �Double Check-Detectar
�� 1PressureVacuumBreaker i�Spill-Resistant Pressure Vacuum Breaker
�
Manufacturer (.�/1 �+�i trv S Model Number �� � Size�_
Located At f/lorv�/��� Serial Number �.5 � q 7� �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �/(�j
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 Tighti�l" Closed Tight �.�1' psid psid psid
Leakedf lo�.. � Leaked. I o'r4 ,3 Did not open f 1 Did not open f J Leaked'�� �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C� Closed Tight f'� psid psid psid
Test gauge used: Make/Model�H7h?61C 4'O—�2����hv SN�(o�CJ�7��C/�
Date Tested for Accuracy: 9 ! /�
Remarks:
The above is certified to be true at the time of testing.
FirmName S� �� Firm AddressG(i�,� �5�✓��s�ri S���L ��
Certified Tester(pr�nt)j�17�C�6��v�L�t►�ertified Tester(signature.�'���.oG�� ���
Firm Phone#9 7�—c1C�0"'��e-J Cert.Tester No. ��J� 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