2015_1112 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 I.D. # 0570040
(Customer)
MAILING ADDRESS:
CONTACTPERSON/PHONE:.�'�A��R�2.0 C� � m2-`
LOCATION OF SERVICE: i1J
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
,j,�l'bouble Check Valve � Double Check-Detector
❑PressureVacuumBreaker ��Spill-ResistantPressure Vacuum Breaker
Manufacturer l,�J[� El►�v S Model Number 3�O Size %=
Located At �/lOi✓(/,�1� Serial Number�.��5 3 9�
r-
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � C
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 Tight?r Closed Tight � psid psid psid
Leaked. b?•D Leaked 1�.3 Did not open I 1 Did not open J Leaked l
Repairs/
Materials
Used
Held at psid Held at psid
Test After � Opened at Opened at Held at
Repair Closed Tight C� Closed Tight[:�_ psid psid psid
Test gauge used: Make/Model ��'1.E�i9G� �2U—�U�7h'� SN:�l����9 7
Date Tested for Accuracy: g i�/ 7�
Remarks:
The above is certified to be true at the time of testing.
Firm Name St� ��� Firm Address�o�i���S v�k/ ��G�S� ��
Certified Tester(print)��C�i�� �U/L��-�Certified Tester(signature��—�z'-!��C�f �u'IJ�(
Firm Phone#9�,r;— ��d''3 7 3 y Cert.Tester No. �S `7d Date �L!/� /__�
* 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