2017_0206 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 far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) f�
MAILING ADDRESS: � ���� /`� �� �d� C y 3�Q � �Sv� 9
CONTACT PERSON/PHONE: av��2, o � �' g
LOCATION OF SERVICE: o�- FJ^- c dlf� t�. N' c.. ' 4 2 � �
The backflow prevention assembly detailed be ow 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 f7�R uced Pressure Principle-Detector
❑Double Check Valve `3Double Check-Detector
C1PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��-tT S Model Number �S� Size 4 �
Located At fJ,,r'(1 2.ti�f y oV�'�'� ��^ Y0.�+ Serial Number �5— D� �q �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? QS
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 n-a psid Held at o-a psid Opened at Opened at Held at
Initial Test Closed Tight❑ Closed Tight ��7 psid psid psid
�� � LeakedC� Leaked�"�' Did not open '� Did not open ❑ Leaked❑
Repairs/ �� �� �� ��
Materials
Used
Held at 1_psid Held at 3 2 psid
Test After Opened at Opened at Held at
Repair �55 Closed Tight� Closed Tight psid psid psid
Test gauge used:Make/Model �P�atv �� � �U—��S s�: c�c�a a a��
Date Tested for Accuracy: f t�T�� �O
Remarks:
The above is certified to be true at the time of testing.
FirmName.(7o� ��'� Lby �C�f(dlr/����irm Address ��(�- �'���e-t.Q C'�,���P.s� ,�/ 7�U�3
Certified Tester(print)--F-Sf�YYl��� Certified Tester(signature)����C ��
Firm Phone# o���(" a�� �Py� S Cert.Tester No.�OD��O��� Date °? ��
* 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