2015_1118 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 'r'l— `��Z-5%�
(Customer)
MAILING ADDRESS: ���r�( �t�`o" �r�I� �
CONTACT PERSON/PHONE: %Yl.e�l,Q' — D � �f — 7
LOCATION OF SERVICE: in. � �t�J cNr �f�i -
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
' iReduced Pressure Principle ��Reduced Pressure Principle-Detector
�ouble Check Valve ���ouble Check-Detector
1PressureVacuumBreaker i ISpill-Resistant Pressure Vacuum Breaker
�t�(
Manufacturer ����`��� Model Number Size
Located At Ul e� Serial Number �"���0��
is the assembly installed in accordance wit 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�� �id Held at�� � ��sid Opened at Opened at Held at
I itial est Closed Tight Closed Tight J'(I psid psid psid
�j Leakedf 1 Leaked� 1 �� Did not open f I Did not open '� Leaked� I
epairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight��l ClosedTightl-1 psid psid psid
Test gauge used: Make/Model l�7^-r il,� TC7� • SN: Q��3 y�7
Date Tested for Accuracy: 3�3''��
Remarks:
The above is certified to be true at the time of testing.
Firm NameJ����B�/` ��C'J'N+�Firm Address •�' ��✓` l�J �J J �� V 1
�+�j � ��oc�3
Certified Tester(print)(./�''�/� ����/Qertified Tester(signature) �
Firm Phone# J�7'�����5� Cert.Tester No.� ����✓ Date f(r� " S�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- City Copy Ye11ow-Customer Copy Pink-Tester's Copy