2017_0605 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: 3) g � ✓ �� C� e � /�i 7�'S�'l
CONTACT PERSON/PHONE: Tv�� �- �,� �? n �- �` ,�?/'/- a a 8 - �'s%�
LOCATION OF SERVICE:
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
�ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
�i
Manufacturer �� �t��S Model Number -��� Size �
, ,_ �,�,y
Located At � /'►1Q�Zr� ��av�� yG�"C� Serial Number ��� �-1 � ,�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Ye 5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
z
Held at � � psid Held at�� psid Opened at Opened at Held at
I itial Test Closed TightB/ Closed Tight i psid psid psid
��55 Leaked❑ Leaked'�1 Did not open ❑ Did not open ❑ Leakedn �
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��'h�!'�tLo 7C -o?GG - 7K� SN; 6�b�7�o1lc�{�
Date Tested for Accuracy: �I �a 3l��D
-�
Remarks:
The above is certified to be true at the time of testing.
Firm Name.�'�} N�� �/�1�' ��lYlo►�'/���Firm A ddress �y/� 1��'l��' �f ,�/�Q.�,, j�i �Sr/ 3
Certified Tester(print��'a��L����/� Certified Tester(signature�-�.�����'-
Firm Phone# e?l y��? ��- �;y I 5 Cert.Tester No. g����`���S Date (p�S!��-
*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