2015_1214 IRRIGATION V 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 recardkeeping 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'J�4�D�Y��O �¢Gi f�G
LOCATION OF SERVICE: (y 3 7 e•¢�2 u,��
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
i=:Reduced Pressure Principle IReduced Pressure Principle-Detector
�"ouble Check Valve �i���Double Check-Detector
�,PressureVacuumBreaker r�Spill-Resistant Pressure Vacuum Breaker
Manufacturer lvr�h�y S Model Number �..SO Size ��
Located At l=�iQ�/.J Serial Number� �g 9 a?��
Is the assembly installed in accardance with manufacturer recommendations and/ar local codes?
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��0 psid Held ato�_�psid Opened at Opened at Held at
Initial Test Closed Tightf � Closed Tight f I psid psid psid
Leaked�l Leaked'I Did not open _i Did not open I I Leakedi ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�l Closed Tight��] psid psid psid
Test gauge used:Make/Model G'dH9��Go YO'2w �f7 v SNf��'!/G�1 '7
Date Tested for Accuracy: g /�� ��
Remarks:
The above is certified to be true at the time of testing.
FirmName S/�� Firm Address � �io?.� �i S/!/�L�Y✓ Si¢C�fT T�
CertifiedTester(print�'l'JiG�1���J�v��v CertifiedTester(signature��,•G���t��
Firm Phone�7�- �po-3��� Cert.Tester No. (�5 � � Datelo? !� `7 � �
* 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