2015_1214 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:
CONTACT PERSON/PHONE:S'�q�+'��+4 Li t�rt�
LOCATION OF SERVICE: �-1 2ti Gt
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-Detectar
��uble Check Valve f�'Double Check-Detectar
-1PressureVacuumBreaker f-lSpill-Resistant Pressure Vacuum Breaker
� c•
Manufacturer 6,c����/nr� Model Number 3 5 I� Size�Z�
� r
Located At ��Orv� �-/�� Serial Number���� �G�6
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? 1. ��
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 Tightl ! Closed Tight �, psid psid psid
Leakedl I Leaked�l Did not open .��i Did not open f i Leaked i
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'�_1 Closed Tight� I psid psid psid
Test gauge used: Make/Model Cr��r/�+�GD ��a�- � h � SN;��J�-/lliy 7
Date Tested for Accuracy: ��/ ���
Remarks:
The above is certified to be true at the time of testing.
Firm Name �� _.�2� Firm Address�G�a E�s�v,�� �/¢C�S� �J�
Certified Tester(print)��c��9�� �v�� Certified Tester(signatur�;��i'"/����`��'''�C
Firm Phone#f 707 ��`3 7�� Cert.Tester No.�s� Date�a �`I � ^
* 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