2015_1125 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: � P/� /ti '
CONTACT PERSON/PHONE: /' " ,s"� " O /
LOCATION OF SERVICE: h4� .✓ ' ! �' ��N� �T �' ti� � �r�.��/f
The backflow prevention assembly detailed below has been tested and mamtained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�iRe uced Pressure Principle �-Reduced Pressure Principle-Detector
ouble Check Valve I Double Check-Detector
�7PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker �
�/ , j�% �
Manufacturer U�/�,/ � 5 Model Number �� � Size -✓
�r9N1�'• I $�9/ CT
Located At �lS���5� Serial Number
Is the assembly installed in accordance with ma ufacture recommendations and/or 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 �• �psid Held at �i� psid Opened at Opened at Held at
Initial Test Closed Tight. I Closed Tight . 1 psid psid psid
Leakedl�'�� Leaked�; Did not open .�I Did not open f 1 Leakedl �
Repai rs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight_l Closed Tight 1 psid psid psid
Test gauge used: Make/Model /((/���t �7� SN: ��Da (�q6.'
Date Tested for Accuracy: �— �0 � ,7
Remarks:
The above is certified to be true at the time of testing.
� /�� —J �� �'a.��
Firm Name � '. Firm Address }7 W• ��1 �! .5�: /`f
Certified Tester(print) ��C1 /7 BK e� Certified Tester(signature)
Firm Phone#�f�`6�7 `��1 9� _ Cert.Tester No.J�4D8 ��fl� Date //'����>
z.
* 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