2015_0114 IRRIGATION DOMESTIC FIRELINE V
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) " wh '��X
MaILiNG a�� ss: �� d 5 �• �6)vd
CONTACT PERSON/PHON •
LOCATION OF SERVICE: , �y�� �__
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
❑Re ced Pressure Principle �Reduced Pressure Principle-Detector
ouble Check Valve [1 Double Check-Detector
�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer t�C�+'J�.(� Model Number ���� Size�
,� '" L 0 � 8
Located At V(�� Ip�t j�.K.S-}u�l0V��3 Serial Number �n� ��
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
Held at psid Held at psid Opened at Opened at Held at
Initial Test Closed Tight�� I Closed Tight �] psid psid psid
Leakedf 1 Leaked❑ Did not open '�-7 Did not open L''� Leaked..I
Repairs/ ,� � rj'�v,.� — �� �� lpfo�"^ � �J'��� (S � G-,..,,� � �0 S t /�C�C S
Materials L L
Used G,it C���� � Vl.o'�' �S'1� k �-�-�'S � 6 /1 T T�ep\
rrer�}- e
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight f 1 psid psid psid
Test gauge used: Make/Model�;���n3 �� SN: �� 0 �0,�7 Y
Date Tested for Accuracy: �a- 3 � ( 1
Remarks: �a`) � 4�� �G��✓� uiQ., 3y ov� �_-� � �/�o�vau �T
I"r,w l, A r(._.�.r�C.�g . w�o s� 0 r ���,Q�s -lo l� rQ��.� �,C c�
The above i certified to be tr e at the time of testing.
FirmName � � ��i�e. S�'I� �y1J�Firm Address P.O, 0 1�1��U �"W�d� ���7`�
Q
Certified Tester(print) ��1.� Certified Tester(signature)
Firm Phone# ���- a3� -.�57� Cert.Tester NagP00I� ��.� Date e �
* 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