2017_0515 IRRIGATION
a� 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: r
LOCATION OF SERVICE• r � DI�1��
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
�I� educed Pressure Principle �Reduced Pressure Principle-Detector
ouble Check Valve [l Double Check-Detector
❑PressureVacuumBreaker i;Spill-Resistant Pressure Vacuum Breaker
Manufacturer ���� Model Number �.5� Size Z��
Located At �o�'� B� �-�i� ��i�� Serial Number � �' ����o
Is the assembly installed in accordance with manufacturer recommendations and/or 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 at�� � psid Held at�_Zpsid Opened at Opened at Held at
Inirial Test Closed Tighti� 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 Cl Closed Tight� psid psid psid
Test gauge used: Make/Model j�/W!«+- �W .S� SN: � '7a�a�8�
Date Tested for Accuracy: �'o�I-I�
Remarks:
The above is certified to be true at the time of testing.
FirmName � C�,c�,� ��. ��S Firm Address�'�'�f� �97 Lt��,c, �� ?S/.�5�
Certified Tester(print)�t �� l.,er��-�Certified Tester(signature) C..�'�'��s---���
Firm Phone# O�` SSb— Z�7 Cert.Tester No. `��fl�v��.s�Date �- �5 ' / �
* 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