2017_0512 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: P 333 C�.STSid E.
CONTACT PERSON/PHONE• S L��r1- ?'�kvp �72 7/ — �673
LOCATION OF SERVICE: l333 �s.s'rS/d�
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
C IReduced Pressure Principle I�Reduced Pressure Principle-Detector
�5ouble Check Valve i;Double Check-Detector
❑PressureVacuumBreaker f=�Spil1-Resistant Pressure Vacuum Breaker
Manufacturer �����u S Model Number 9�a Size Z��
Located At 1�oRa7� C��R M�T� �� Serial Number 7�S 323
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Y�
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 z�� psid Held at�''� psid Opened at Opened at Held at
Initial Test Closed Tight�Y Closed Tight psid psid psid
Leaked�l Leakedl�l Did not open ��� Did not open ❑ Leakedl;
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i� Closed Tight'-1 psid psid psid
Test gauge used:Make/Model � w ���—S SN: D// 7 OS6 a
Date Tested for Accuracy: �—�� —�7 �
Remarks: i
The above is certified to be true at the time of testing. i
FirmName ��fT�d n2�'t4�-�v��A�— Firm Address ��S�a P�o 12d � ,�R�C�.r!-s 7SZ�3
Certified Tester rint � ��s�� Certified Tester si nature - ��-�.--
�
�P ) � g ) �
Firm Phone# .z�� 3�/ —Q�oO �P Z)O I 1 o SS S--f 2—/'7 I
Cert.Tester No. Date I
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS i
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy
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