2017_0504 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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: o ��' l,J��51 fj�/�-Y�'�
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 uced Pressure Principle Reduced Pressure Principle-Detector
-' ouble Check Valve �Double Check-Detectar
7PressureVacuumBreaker Spil1-Resistant Pressure Vacuum Breaker
Manufacturer L��h /�v� Model Number �,7� Size_�_
Located At ��i�!/ ��y2� Serial Number j� /019 7�T_
Is the assembly insta Il ed in accordance 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� � psid Held a�'� psid Opened at Opened at Held at
Initial Test Closed Tight(� Closed Tight �-�' psid psid psid
Leaked ! Leaked.i Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight_ Closed Tight pS�d psid psid
Test gauge used: Make/Model Cv�n Yv� h cJ SN: d�z''l�-1���'! �
Date Tested for Accuracy: �i -
Remarks:
The above is certified to be true at the time of testing.
Firm Name ,S � ��� Firm Address(OG,�� �✓��'� �/�P,,1� ~ ��'
" �-�?�� ,� �
Certified Tester(print)rYl zc%�, C L� Certified Tester(signatur ,� C�
Firm Phone#f'���� � ��'U-- 73 y Cert.Tester No.�j`���j Dat�1�-1�
* 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