2017_0403 (2) IRRI6ATION�_ 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 MAINTENA�1110E REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) ,
MAILING ADDRESS: :=�1�, :,�,f, �, ,�: �.� �, , �'�a;r�l� 7✓ <
CONTACT PERSON/PHONE: '��
LOCATION OF SERVICE: �",�,�;� ,'�€.;�'r��.%',t jrt '
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
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Manufacturer ``� � ��; �r .� Model Number � -� `�-�` Size ��
.
��`�-�- r�r�_t� f � � � t' �
Located At � Serial Number e ,..
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �`�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Doubie Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at �•� psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�" 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❑ Closed Tight❑ psid psid psid
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Test gauge used:Make/Model%���'J�.f,f:� �3('-,��_;'.:` ��'£i��� SN: i�!;l,f�� f�
Date Tested for Accuracy: �_�-!7� /''
Remarks:
The above is certified to be true at the time of testing.
�irmName :��i��Ci U�iy7� ���'`—.l 'i.'I V Firm Address ;�?� '� ;�fl� .`��f��� �fr/ '(/�l.�ytE'd�� l��r �::'�r �!
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Certified Tester(print),!,,�', ':,;���`���-�,�`` Certified Tester(signature) � �� r��-�:• `�'���_
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Firm Phone# �1 ��,,����l �� �?� Cert.Tester No. ��f �-',�� �',}� 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