2017_0425 , � _
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: "�!s L �-(v,�s �-�•� �1-� GD�a,II �7`� 7��`�
CONTACT PERSON/PHONE: JZLxs - Zc� 7�i 3 23
LOCATION OF SERVICE: 5�
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
�Re ed Pressure Principle �Reduced Pressure Principle-Detector
^l ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker -1Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��Go Model Number �� Size�
Located At �y �� i��, Lc�� Serial Number N� 33d'G 2
Is the assembly installed in accordance with manufacturer recommendations 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 Z G psid H at Z,� psid pened at Opened at Held at
Inirial Test Closed Tight��� Closed Tight psid psid psid
Leaked❑ Leaked�ri Did not open �l Did not open !� Leaked❑
R pairs/
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 lr'<<� �P'�" ��/S"S— SN: ��iG f�37 Z
Date Tested for Accuracy: /�'-�—/G
Remarks:
The above is certified to be true at the time of testing.
FirmName/n.G�� CD�,4���-� Firm Address��U �= f-1w� �� S4;f�e. Zfv
��,.�.��.„.�;l/�- -�y 7^5�3��
Certified Tester(prin�.� /;�� ..-� Certified Tester(signature)�' �----
�—
Firm Phone# �(�� �>i r/9� Cert.Tester No.�3�:bi�/�3Z Date �` '���j 7
* 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