2015_1214 IRRIGATION V 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:
CONTACT PERSON/PHONE: ' y�0 �4 G
LOCATION OF SERVICE: �-J' A-� ,TL
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
' Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
��oubleCheckValve CJDouble Check-Detector
[�PressureVacuumBreaker f ISpill-Resistant Pressure Vacuum Breaker
3 !r
Manufacturer �i�'��1?is1iS Model Number �Sd Size �!
�
Located At ���'1 N�/l.rd Serial Number J� `�1-3`� `7 S^O
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � �5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held ato��psid Held at��{psid Opened at Opened at Held at
InitialTest ClosedTight�l ClosedTight f��l psid psid psid
Leakedl I Leakedl I Did not open ' Did not open �� I Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Neld at
Repair ClosedTightL] ClosedTight'�.7 psid psid psid
Test gauge used: Make/Model�'�►B�Gp �d-�vrr/ u SN:��� ��/� 7
Date Tested far Accuracy: 9 / !/��
Remarks:
The above is certified to be true at the time of testing.
Firm Name ,� � -��✓2— Firm Address U�i����S f✓�fl�'`Y ��C�� / �
Certified Tester(pr�nt��G��!!�-�v2�J� Certified Tester(signature,��/l�� ��
Firm Phone#97�'�f�'�' 3 7�� Cert.Tester No. ��9� Date �a �Y��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