2017_0313 IRRIGATION 1� 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: � �U W i rv�'/,� 7'L=
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
�Bouble Check Valve 'Double Check-Detectar
'-iPressureVacuumBreaker Spi11-Resistant Pressure Vacuum Breaker
Manufacturer l.0� �. i•2 S Model Number -�S CJ Size ��
Located At�/�vnf! ���¢,2,Q Serial Number iT ,,�o� `�� -� 7
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ` L s
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�� 5 psid Held ata psid Opened at Opened at Held at
Initial Test Closed Tight�� 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 Opened at Held at
Repair Closed Tight '� Closed Tight ps�d psid psid
Test gauge used: Make/ModelC�rri�SQO�cO `Z��a�o �� v SN:����7/(�cl 7
Date Tested for Accuracy: ��o��i � G
Remarks:
The above is certified to be true at the time of testing.
Firm Name �/� ,,��� Firm Address�j Ci o70��� S�!/'�,['-� /QC`�5 b ��
Certified Tester(print�'!'1�C�s9�L �����Certified Tester(signature �C.�� `�
Firm Phone# �7�— dlc��">j+7��'/Cert. Tester No. �5 �� Date 3 /� �/� �
* 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