2015_1114 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: �3�
CONTACT PERSON/PHONE: �n �l i Il
LOCATION OF SERVICE: � �
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
C,Reduced Pressure Principle C�Reduced Pressure Principle-Detector
�ouble Check Valve I I Double Check-Detector
❑ ressureVacuumBreaker �Spill-ResistantPressure Vacuum Breaker
Manufacturer �(./t� Model Number. �J C� Size �Il
Located At /lk'�� �� �� � ���al Number /I � �6 Z s-3
Is the assembly installed in accordance with manufacturer 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
1 r����� Held a��� psid Held at��� p id Opened at Opened at Held at
Initial Tes �1 ked Tigh� Closed Tight� psid psid psid
e e d ' Leaked'.I Did not o pen .1 Did not o pen ' 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 C i psid psid psid
Test gauge used: Make/Model ��tJ ����� Ty � SN: (�3b`�0 ���
Date Tested for Accuracy: �i! S ��
Remarks:
The above is certified to be true at the time of testing.
FirmName !�� ���� Firm Address rU "'ti Z�v[��r / I(/���""'�d 'r��Q2�
Certified Tester(pr:nt) ��1.� �(� Certified Tester(signature) � �
Firm Phone# Z��SOZ- �I�� Cert.Tester No. ��a��Z�� Date �I � — �
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow- Customer Copy Pink-Tester's Copy