2017_0313 IRRIGATION 'V� 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 LD. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �7�� 4J f N+�Sc�/�
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 ��Reduced Pressure Principle-Detector
�Double Check Valve -,��Double Check-Detector
-�PressureVacuumBreaker ;Spill-Resistant Pressure Vacuum Breaker
Manufacturerl.r/;ti E7���i Model Number --� S�U Size�
Located At f-�ir+/I i/�/�-� Serial Number� �y 5 G�Y 3
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � L�
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
Initial Test Closed Tight�� Closed Tight � psid psid psid
Leaked. I Leaked` ' 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', I Closed Tight ' psid psid psid
Test gauge used: Make/Model��b��A�U �-1�-�i7J � �v SNU(��'� � �' � �
Date Tested for Accuracy: ���`� i (r
Remarks:
The above is certified to be true at the time of testing.
FirmName S/� ��2 Firrn Address �G�� L'9 S��fG� .��Gt/SL T.�
Cerrified Tester(print)i'�'1'�����l- ����%Certified Tester(signaturey�%��_�sr.-����--��'���_
Firm Phone# J��- �i�U�- �7 ��! Cert.Tester No. � � �lC� Date�� � / � '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