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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: ST��v�R�Q 9 G� F�L om t�5
LOCATION OF SERVICE: SD [�0 E
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�-=:Reduced Pressure Principle -1Reduced Pressure Principle-Detector
�'bouble Check Valve ��l Double Check-Detector
f 1PressureVacuumBreaker f �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �J��f,�rd S Model Number �.$'C� Size �
Located At �2oh`T �/��2 (D Serial Number /4 ,s�7�-�`7
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? l �
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� Closed Tight 'r!� psid psid psid
Leaked f 1 a� Leaked':1 p'�. � Did not open i Did not open 1 Leaked' I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight L�, Closed Tight f i psid psid psid
Test gauge used: Make/Model Co��/IA�p 56-�?or� /h u SN:��O�7/�i �"! �
Date Tested for Accuracy: �'l / �� S
Remarks:
The above is certified to be true at the time of testing.
FirmName S� ��2 FirmAddress�G��?r�s�v��w s��l��b ��
Certified Tester(print)/'!?i G�l��-,F>v2�1�Certified Tester(signature)��/�.•��� �G.c�,�(
Firm Phone#r97v�- 9�d'��.��J Cert.Tester No.�-S9� Date�/ ��� /f�
* 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