2017_0628 IRRlGATIaN DOMESTIC FIRElINE
The following form musi be compteted for each assembly tested. A signed and dated original
must be submitted to the pubiic water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLV TEST AND I�tAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: �--"'^
CQNTACT PERSONIPHONE: a
LOCATION OF SERVICE: � �
The backflow prevention assembiy detailed below has been test and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
_:FZe ced Pressure Principle -Reduced Pressure Principle-DeCector
uble Check Valve Dauble Check-De,tector
Pressur�VacuumBreaker � Spill-Resistant Pressure Vacuum Breaker
Manufacturer j��t7w+,� Model Number 3SCl Size__���
Located At � � ��� Serial Number l�633�3Z �
Is the assembly insialled in aecordance w�ith manufacturer recommendations anrLfor local codes? �S
Reduced Pressure Princi le Assembtv Pressure Vacuum Breaker
Doubie Check Val��e Assembiv
Relief�'alve Air Inlet Check Va1��e
I st Check 2nd Check
Held at z��ps' Heid at��p ' Op�ned at Opened at Heid at
Initiat Test Closed Tight Closed Tight psid psid psid
Leaked Leaked id not open Did not open Leaked
Repairs.`
�+(aterials
Used
Held at psid Held at psid
Test After Opened at Op�ned at Held at
Repair Closed Tight Ciosed Tight psid psid psid
Test gauge used:MaketModel (b _ _SN: �Z 1?i 256 S
Date Tested for Accuracy: 3 Z i-1�
Remarks:
The above is certified to be true at the time of testing.
Firm Name_ v�st�� Firm Address � �l� z �i �
Certefied Tester(print) Certified Tester{signature)
Firm Phone� `f12 �/7-��_Cert.Tester No.17i���_Date �� �7
*TEST RECORDS MUST BE KEPT FOR A`T LEAST TH[tEE YEARS
**USE ONLY MANUFAGTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy