2016_1221 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
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: '� �;L b�—�3 'Z 19
LOCATION OF SERVICE: �1 1� ��rn�on S�
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
�❑ duced Pressure Principle �Reduced Pressure Principle-Detector
oubleCheckValve ❑Double Check-Detector
�1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer W` ��'' 'n S Model Number Ej S t� Size 3/�
Located At �ti� i��'1�'C '�L'�-`� � Serial Number /T S 9 S 9 S-�'
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Pi-S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
Held at�psid Held at�� ps' Opened at Opened at Held at
Initial Test Closed Tightl� Closed Tight ,_ psid psid psid
Leaked��i Leaked��I 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 n psid psid psid
Test gauge used:Make/Model e �n b��p ��'� SN: �ZV S OS6 9
Date Tested for Accuracy: C��7 "/�
Remarks:
The above is certified to be true at the time of testing.
FirmName !�,(,(,u✓) l�i�q(.1.� d Firm Address�. d. �d� � � I�L1`� Cj�/
Certified Tester(print) ���i U�I� �(��- Certified Tester(signature) ��
FirmPhone# `�� 1� ��5—Z19� Cert.TesterNo. ���d�Z�Z Date ��JZ�—�,�0
* 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