Untitled (66) 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. #�570040
(Customer) _
MAILING ADDRESS: "�'s�
CONTACT PERSON/PHONE: L`�,��� ��y �13p �q �
LOCATION OF SERVICE:��7 L�be,c�- •
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle OReduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker L�Spill-Resistant Pressure Vacuum Breaker
Manufacturer �l.,1�� Model Number��o[�$ Size l�
Located At Serial Number ������
Is the assembly installe 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��id Held at�ps' Opened at Opened at Held at
Initial Test Closed Tight Closed Tight psid psid psid
Leaked❑ 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 Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model���s�0—2�1b—�kJ`—� SN:Qy t y 2�ro�
Date Tested for Accuracy: 5/,!/!(p
Remarks:
The above is certified to be true at the rime of testing.
FirmNamel�,ou•.o�lxr� ��s ��,e��Firm Address���. 7��. ,o�L,ac-1.� �, �68
Certified Tester(print)�4�M�aV iti� Certified Tester(signature) .
t
Firm Phone#21'1,�Itf,319'•1 Cert.Tester No.3POOLL9�IS Date f'��i io
*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