2017_0329 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:��� ��'�7 �-' �
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �O� p�'� �YJ [2.9�5 �
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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
�R duced Pressure Principle Reduced Pressure Principle-Detector
ouble Check Valve Double Check-Detector
' PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
i /,,
Manufacturer �iCJy �/�' '-�3 Model Number ��o X G �' Size�
r �� ° �I
Located At yo +�' � 4-r Serial Number� ���o�-
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �-r5
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���psid Held at�psid Opened at_ Opened at Held at
Inirial Test Closed Tigh ��� Closed Tight � psid psid psid
Leaked� � Leaked '�� Did not open Did not open �� Leaked ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opcncd at Hcld at
Repair ClosedTight � ClosedTight� ' psid psid psid
Test gauge used: Make/Model (,�i�K�t c,-c.s' SN: �-�/3('��%
Date Tested for Accuracy: � Y�� �� �
Remarks:
The above is certified to be true at the time of testing.
� �/�
Firm Name ' ���-tYs�vC' Firm Address �d 27d1�,��f0���
CertifiedTester r;nr c�Yt os -'" --
(p )� � '�`� Certified Tester(signature) �
Firm Phone#���� �� 83�$' Cert.Tester No��00�3��� Date � -�-y � �
* 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