2017_0306 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: 2 S Z �� C�.��erJ
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: 'L_ Z ,C'
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 i�Reduced Pressure Principle-Detector
�Double Check Valve CiDouble Check-Detector
❑PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
Manufacturer�it�l{lL��JS Model Number ?v SC5 Size �� t
Located At � Serial Number�(p�� � g�
Is the assembly � stalled in accardance 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 at Q�3 psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight,� Closed Tight 5� psid psid psid
Leakedf� Leaked��� Did not open �,�' Did not open i� Leaked,n
Repairs/
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 `t'`f'— s SN:�l�l��0 g
Date Tested for Accuracy: / �!l—(7'
Remarks:
The above is certified to be true at the time of testing.
Firm Name���w.J c.I�.ELocc� Firm Address ZD1JZ ?'�N�O ��-
��— �oJ � �"� ��i '�
Certified Tester(print �� �i� N.�ertified Tester(signature) �LZ�
Firm Phone# `Z��o� �TCert.Tester Na [7 Date �v �-�i"�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