2017_0504 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: � �1'►'I��'� L0�" � Cr�� �Q-� �h� ��k
CONTACT PERSON/PHONE:
LOCATION OFSERVICE: ��5 S pU1f'aV1 "r6+��(<(Jl�'X-�I� TX �1501°I
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
�educed Pressure Principle Reduced Pressure Principle-Detector
����Double Check Valve Double Check-D�tector
Pressur�VacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �1��V1S Model Number 31S Size ( "
Located At 1�-�- m.(,�-1' a�- I nt�l'S��.fi on Serial Nuinber �} 4 I�15
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
5 I� I �, Held at � .�psid Held at 1 QZ psid Opened at 3•(0 Opened at Held at
Initial Test Closed Tight✓ Closed Tight � psid psid psid
Passtd 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 (,��(�Q �-{�- Z�Q' '(�L sN: 3 s I 35 Z.
Date Tested for Accuracy: � - 2�p� I 1
Remarks:
The above is certified to be true at the time of testing.
FirmName� �{�j'�V����YIL• Finn Address P� ��X 1, �G�Y1S� T� 75�1oJ
Certified Tester(pr�nt) 'T.p__, ►'Y��YVI►'1 Certified Tester(signature)� �
Firm Phone# �D�—��5' 213q Cert.Tester No. ��0131�S Date S�y'17
* 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