Untitled (9) 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) �j � �11 ?
MAILING ADDRESS: // � O/�T W ]7-G.� �J�
CONTACT PERSON/PHONE: P —� 3
LOCATION OF SERVICE: PkWy . � a
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
-]Reduced Pressure Principle :]Reduced Pressure Principle-Detector
-7DoubleCheckValve -1Double Check-Detector
�PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer
�p`��� Model Number ��M� Size�
Located At� �Llel.-� `— 1 /`�/�G�•c.(/�N /'9�C�Serial Number � � �G
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? V �
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
p�l�lj Held at . psid Held at p.�psid Opened at� Opened at Held at
I tial Test Closed Tig ti� Closed Tight C psid psid psid
Leaked. 1 Leaked �l Did not open I Did not open f' Leaked���l
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C�� Closed Tight��I psid psid psid
Test gauge used:Make/Model W/�1C1/1�S TGS sN: �,/ioo96s'
Date Tested or Accuracy: �'���
Remarks:_,_����� Y 1�.5 fJt�� � �I/� �Ql��.
The above is certified to be true at the time of testing.
Firm Name�� �I�LDIi✓��I�S Firm Address ��•Z. �� � ��C. �V /�7 �
Certified Tester(print)�E- �������� Certified Tester(signature)
Firm Phone# �.Z'+t.f,3'.Z�Jr7 Cert.Tester No..(�DD��g�3 Date /�—���-G
* 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