2017_0503 IRRIGATION DOMESTIC FIRELINE �r
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: SOO �,r�� ofi- u tl l �i S
CONTACT PERSON/PHONE: o•� ��t.��}'tir.c 2�`l� S N� O i 7S
LOCATION OF SERVICE: S O Ca 7'I(�t' ����- f��U y' Co P�C I/ TX 7Sv f�1
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 �lReduced Pressure Principle-Detector
❑Double Check Valve f�j.Plouble Check-Detector
CPressureVacuumBreaker -iSpi11-Resistant Pressure Vacuum Breaker
Manufacturer �� w�t�S Model Number 77`r Size ��
Located At 1�f\ (�c�N� }- or� w e�ts�dt 8��erial Number l OO S�`i 7
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? xPs
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
,�S 5 1 st Check 2nd Check
Held at psid Held at psid Opened at Opened at Held at
Initial Test Closed Tight:�� Closed Tight 'i 1 psid psid psid
Leakedl ' Leaked�'� Did not open �'� Did not open L_] LeakedLJ
Repairs/ R�P�aC��
Materials
Used C1�ec K
Held at��psid Held at ;Z, psid
Test After Opened at Opened at Held at
Repair Closed Tight:� Closed Tight� psid psid � psid
Test gauge used:Make/Model /t Po jjo L(O ^,�p� �-��CS(.( SN: 0���,�Q/�
Date Tested for Accuracy: fVovl t(� aO i b �k �c��f- �'7�,�J?-►�C
Remarks:
The above is certified to be true at the time of testing. y�e5
FirmName Ad"1«��...� �',rc �Fo�cF;�+ Firm Address IOS7.S tf'i S �� ��rK �,/�q %�( 1,s,2�8-
Certified Tester(print) �o;en tO ►rr p�,,.� Certified Tester(signature) � �y
Firm Phone#,�C `��,3 C/q -��� / Cert.Tester No. B�oo tS9 3o Date c5�3f/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