2015_0114 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) n '
MAILING ADD ESS: I �� S (��:1�-I� �(�D� C.�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: ` �
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
❑ educed Pressure Principle JReduced Pressure Principle-Detector
j�Double Check Valve ❑Double Check-Detector
�1PressureVacuumBreaker f 7Spi11-Resistant Pressure Vacuum Breaker
Manufacturer�{Ie�C� Model Number ��i Size 3_ ��
r
Located At�]IA� 1,i11�hP�IDlAL1 �L��� dd�` Serial Number Q��.,Z,��
Is the assembly installed in accordan�ith 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
Held at psid Held at psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight -1 psid psid psid
Leaked❑ LeakedC�� Did not open '_7 Did not open f' Leaked� 1
Repairs/ �2-I '#�/ #-3 � �$� ,�5� �OG�S
Materials �rS
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight' J Closed Tight❑ psid psid psid
Test gauge used: Make/Model�������i n S � � SN: D(p D'j OS 7 �P
Date Tested for Accuracy: �a �3 � I`�
Remarks:
The above is certified to be true at the time of testing.
Firm Name j�.Q- �,t_ ��{'i���s'h�rm Address�,d•�a)C 7�1.S�g �-1'�iJo��'�,�76l7S
Certified Tester(pr:nt /u-o Certified Tester(signature)
Firm Phone# ��7'��b� 'S�7? Cert.Tester No. iDPO o(S3 Q,� Date /y /
* 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