2017_0228 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 I.D. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �7D CJ�w G-'�. G�=
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable paraineters.
TYPE OF ASSEMBLY
-1Reduced Pressure Principle -��Reduced Pressure Principle-Detector
:2�CSouble Check Valve Double Check-Detector
IPressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer �vs��7�/'�5 Model Number 3-sb Size�
�
Located At ���''� %A`/� Serial Number 1�'� �/-�o�SJ
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t 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 1� �psid Held at ��psid Opened at Opened at Held at
Initial Test Closed Tight 1 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 psid psid psid
Test gauge used: Make/Model�o�� t p �10-?v� �fJ V SN: O�o o�i !G� "]
Date Tested for Accuracy: � �9 l�G
Remarks:
The above is certified to be true at the time of testing.
Firm Name �i� -��� Firm Addres�G.��G��5 jV��1�'✓ .�.���� !�"
, Certified Tester(print���?L'Z. ��.L�iL Certified Tester(signaturey''y��''���.i���� ��
Firm Phone#�7a_ �G— ��3Ll Cert.Tester No. D s 96 Date ? 6!
* 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