2017_0309 IRRIGATION DOMESTIC FIRELINE�
The following form must be completed far 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) c
MAILING ADDRESS: � '�n � � c�C�I�
CONTACT PERSON/PHONE: ? � �-}�—
LOCATION OF SERVICE: K `,
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
�JReduced Pressure Principle �Reduced Pressure Principle-Detector
`I�Double Check Valve � �Double Check-Detector
i IPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer�M.�i�_Model Number C��1� ��� Size ��
Located At �`�� (,'( ���� Serial Number����{
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at2°� psid Held at�'� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leaked�� Leaked� Did not open l 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_:i psid psid psid
Test gauge used:Make/Model il�W(,�� �I�c7— J� SN: Q t� � (p Z� � �_
Date Tested for Accuracy: L�2� ' � �Q
Remarks:
The above is certified to be true at the time of testing.
FirmName �� 1� ��G�,,7 Firm Address2�(1� (�n11 n�e� �`�J
Certified Tester(print)�ypti, ���;un Certified Tester(signature)
Firm Phone# �,-����j"'�� U� Cert.Tester No. Date� 1
* 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