2015_1217 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: ��� �/�`� /� LG�S ,
CONTACT PERSON/PHONE: �
LOCATION OF SERVICE: � � �
The backflow prevention assembly detailed below has been tested a maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
f�R ed Pressure Principle ❑Reduced Pressure Principle-Detector
� ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker '7Spi11-Resistant Pressure Vacuum Breaker
/� �•- �- s'/
Manufacturer 6i(��L/1 J�SModel Number � �Q Size �
Located At ��� � ����Seriaf-N�i�tber �L/ `�7-� `�O
' � �
Is the assembly installed in accordance � 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 a��psid pened at Opened at Held at
Initial Test Closed Tigh Closed Tight psid psid psid
Leakedl I Leaked❑ Did not open ❑ Did not open ❑ Leaked'�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTigbt C! psid psid psid
Test gauge used: Make/Model�%t/�v��•t�� �v c� SN: �-�` c3��.�`
Date Tested for Accuracy: c3/���/Jr
Remarks:
The above is certified��rue�rir�e of testing. 3��r�c� � �p/��� �/��-�
�1
FirmName������������-"F'irm Address ������� ��� � s%rE�"��
� ,� �g�
Certified Tester(pr�nt) ���%�//�Certified Tester(signature)
Firm Phone#C/�/ ^����� Cert.Tester N���������Date � ���
�
* 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