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 recordlceeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REYORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) n
MAILING ADDRESS: (�_�l�2t1'1Gi�Pt�' 1...�`^C' r�r-�F�� (
CONTACT PERSON/PHONE:Ln�I�"S (�ic a5 2�`-� 'y�1 S��SO`tU
LOCATION OF SERVICE: (0l5 !►��'�n�/Q� C�ri vG
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 '-!Red�iced Pressure Principle-Detector
VQ�Double Check Valve ' !Double Checic-Detector
' IPressureVacuumBreal<er �-�Spill-Resistant Pressure Vacuum Breaker
Manufacturer W Ol��S Model Number ��� � � Q'1 Size Z
Located At �"'f01�1� p� ��� C �� Serial Number �5 ��s�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e S
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 at ��.3 psid Opened at Opened at Held at
Initial Test Closed TightiyP Closed Tight Jf psid psid psid
Leaked! I Leaked! I Did not open i Did not open ' Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Ope��ed at Opened at Held at
Repair Closed Tight I Closed Tight' I psid psid psid
Test gauge used: Make/Model �M�aC U �4 '� �p SN: Z`fgDDO
Date Tested for Accuracy: 9[j�o1(�(0
Remarks:
The above is certified to be true at the time of testing.
FirmName ���` �sb Firm Address �3�� �'`�r'Q �P` �`✓ � e�`
` , �
� Certitied Tester(prznt) U[���Certified Tester(signature) �
Firm Phone# ����� r�r���� Cert.Tester No. ����D��� Date f�^ �"� ��'
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REFLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy