2017_0503 IRRIGATION DOMESTIC FIRELINE X
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: � 2`( O ���J�`c�c1a( f�;Q_ Co el� TX 7 S o(
CONTACT PERSON/PHONE:_ o n �c,�l� r,'e 1 �`I ^SY�'r r D7 7S
LOCATION OF SERVICE: ��14 ,(�,'�s,�(��� �� . �o pp��� lX 7SOJ9
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 �Reduced Pressure Principle-Detector
❑Double Check Valve fl�Brouble Check-Detector
❑PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
Manufacturer (�t/G� S Model Number 7�y Size�
Located At_4/1 �i✓,��.� DR. ��r amr►ol �� y�„/f Serial Number lJ�,�.� �
Is the assembly installed in accordance with manufactwer recommendations and/ar local codes? yP-S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
� � Double Check Valve Assembly
�y Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at psid Held at psid Opened at Opened at Held at
Initial Test Closed Tight❑ Closed Tight �� psid psid psid
Leakedi-] Leaked-�1 Did not open �:7 Did not open ��'� Leaked❑
Repairs/ � D � p��(�C c�
Materials e���c c Il
Used C11eC.k ChecK
Held at � psid Held at �{•I psid
Test After Opened at Opened at Held at
Repair Closed Tight� Closed Tight� ps�d psid psid
Test gauge used:Make/Model �Q�j �� ��J�Oo-'TI�S(g SN: 47/y2o! S�
Date Tested for Accuracy: /�0✓ l�,a al6 ,(�� j�S �- �'-���q c ,�-n C
Remarks:
v
The above is certified to be true at the time of testing. Y�,S
Firm Name Awie��c.... F:re P���:,�Firm A ddress l05 7S ir i s�c pzr 1� ,Q.�.!/� s TX 75'2,;�
Certified Tester(print) �o rt nre �.ppl.•..�Certified Tester(signature)��j�'�
Firm Phone#;Z�`I-.3�'�-,22�2 1 Cert.Tester No._(3POaJS93 Q Date S ,3 i
*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