2017_0317 IRRIGATION DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ori inal �
must be submitted to the public water supplier for recardkeeping purposes: �Q�(�`�-� p� ���`
� V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MaiLrN�a��REss: _ l 20 g S�rd � ���a. � �
CONTACT PERSON/PHONE: I�I (� "
LOCATION OF SERVICE: l iZO $_SAr'��t
�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�_:iReduced Pressure Principle rlReduced Pressure Principle-Detector
`r�DoubleCheckValve ��'Double Check-Detector
�'PressureVacuumBreaker 1�pi11-Resist�nt Pressure VacuumBreaker
� a � �
Manufacturer W �� Model Number � Size
Located At �'� �bl�-�.r 1�11 S�'�G� Serial Number � a 8 g � g
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�S Held at�psid Held at�p id Opened at Opened at Held at
It'tial Test Closed Tight'� Closed Tight � psid psid psid
Leakedf � Leaked'�, I � Did not o en �__� -�
p Did not open � Leaked. I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� Closed Tight��� psid psid psid
Test gauge used:Make/Model UV ���N 5 1 � S SN: ��o Q 7� 7 g�
Date Tested for Accuracy: �3I� �O
Remarks:
The above is certified to be true at the time of testing.
FirmName T71L-Tes�-- Firm Address� ao6 S t�.��� �k�• c�.�0� �(Q,`lerl'X.
Certified Tester(print) �C� t� '�o'(1Certified Tester(signature)
Firm Phone# p�7�3 7 9—O g5 � Cert. Tester No.$Q00���7a Date 3 '� 7—�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