2017_0606 � L/
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: v� O �� ���e- � �
CONTACT PERSON/PHONE: `�\�- �G � �'``L ��-v' � `
LOCATION OF SERVICE: �v� �� � ('�G�� �oc�tv� �toS. o2,c�'0 �i;V � �e�.
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 '
'�DoubleCheckValve ❑Double Check-Detector ,
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �N ��C"@ Model Number ���'�� �• Size / Z
�ir�'��oms
Located At �1�.�v S<,�v� F �aorv�� `� Serial Number �?j (7 � a2 � �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �'S •
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air inlet Check Valve
1 st Check 2nd Check
G` � (°�i � Held at�psid Held at�psid Opened at �� Opened at Held at
Initial Test Closed Tight� �: Closed Tight � psid psid psid
/�Q 5� Leaked�J LeakedJ Did not open '� Did not ope U Leake ❑
Repairs/
Materials
Used
Held at , psid Held�at psid
Test After Ope ed at Opene at Held at
Repair Closed Tight i 1 Closed Tight i! psid psid psid
Test gauge used:Make/Model �"�� �W Q S� �L�S�—� SN: ��0 ��' �� �o ,1
Date Tested for Accuracy: ��"�J ��- � � -
Remarks:
The above is certified to be true at the time of testing.
FirmName \ . � •�,n�� S �-P�'irm Address ��j " 'S (� \ o V1t� �Q � �� •
Certified Tester(print)� � r��.Certified Tester(signature) � �
Firm Phone#��f�2� ��� 'f�3�� Cert.Tester No.�f (?O�G��� Date �'" � "' � �
—�
*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