2017_0405 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: � �) G✓!rr/(��.jt�
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
���louble Check Valve -:Double Check-Detector
' PressurcVacuumBreaker -Spi11-Resistant Pressure Vacuum Breaker
Manufacturer LtJ� L� t.v S Model Number � S1O Size�
Located At �/'L�J�''�� L/�9-�� Serial Number�'I TD! to S� �
Is the assembly installed in accordance with manufacturer recommendations andlor 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�'V psid Held ata� �psid Opened at Opened at Held at
Initial Test Closed Tightl�-- Closed Tight ���� psid psid psid
Leaked I 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'� psid psid psid
Test gauge used: Make/Modelco`+r�cn Y�-�� /�1 c� SN:(,�o�Gt--/!ji �' 7
Date Tested for Accuracy: �/o2ai �/ L
Remarks:
Tbe above is certified to be true at the time of tesring.
Firm Name s/� ...��� Firm AddressZrG,2� L�95jv�Cz,. ��C�SG� ,r(/
Certified Tester(print)�'I4�e�L �u�1��,�Certified Tester(signature�y��%�,2�� ��_�
Firm Phone#f �a2- �/�!�' ��� Cert. Tester No. ��j �l(1 Date L "- /
* 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