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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: G, � tn. ��`
CONTACT PERSON/PHONE: r - 6 U
LOCATION OF SERVICE: O �aP w � � � I
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 ,Reduced Pressure Principle-Detector
Double Check Valve Double Check-Detector
�Pressur�VacuumBreaker Spill-Resistant Pressure Vacuu�Breaker
0� � /
Manufacturer �� Model Number � Size 2
Located AtS�� �°�Tr'`�11T WIacU ���� Serial Number tt6Zq��
Is the assembly installed in accordance with manufacturer recommendarions and/or local codes? �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 -1•7 psid Held at —1�� psid Opened at 2•0 Opened at Held at
Initial Test Closed Tight-I Closed Ti ht � '� psid psid psid
Leaked Leaked�� Did not open . Did not open Leaked
Repairs/ � �
Materials p �I ..� IL��•
Used f`'�'`'b��� �
Held at psid Held at psid
Test After Opened at 3. � Opened at Held at
Repair Closed Tight;_' Closed Tight psid psid psid
Test gauge used: Make/Model �..1• �K.�(1 �G"S SN: ObC3� �7D"I
Date Tested for Accuracy: S i3 1�
Remarks:
The above is certified to be true at the time of testing.
Firm Name /''f�I �eS� Firm Address��DS 1�� 1�Gt�. S� �O�
f' �:k�f�,� �T1C� z4�i
Certified Tester(print)��,y�p,�' ���(� Certified Tester(signature)
Firm Phone# ��7-3�� �s� Cert.Tester No.�PC30 ���7Z Date FZ. 2 ��p
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy