2017_0425 �.
IRRIGA710N ,i� DOMESTIC FIRELINE
The fflllowing 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: `-J' � �.- � u,; -}�- - ' ��" ��u.,'
CONTACT PERSON/PHONE: ,�- -�r; �'-- �
LOCATION OF SERVICE: �;_`...t
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
❑Re�d �d Pressure Principle ❑Reduced Pressure Principle-Detector
❑H'oubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �C��r� Model Number �''� J Size�
Located At ���., �-�`�-- ,�, �..���-, Serial Number /��_ ���'�(, L
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y� S
� 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 Z-G psid HeJd at�(z psid Opened at Opened at Held at
Initial Test Closed Tight❑ Closed Tight psid psid psid
Leakedn Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
� _
R airs/
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 f `� ��' �1� =r � � � SN: <�°`,��i: �•�' � y
Date Tested for Accuracy: '' '- =� t i; `
Remarks:
The above is certified to be true at the time of testing.
�
FirmName f`� ,! � ,���, _ Firm Address f : _. �- ' � �� �s:t:�rs- 2 Et�
` � ��a���: �_-�?1��. -���, ;��. �-r—z
. J .
' "
Certified Tester(print)y,,.�/;:,'w. � Certified Tester(sigq�ture)_ � �=_=�
r .
:, :s � __
--`� -__-�--__
__
n `�w�,�.,_..---
(
Firm Phone# �'i,j e`;�� UL= �z r_:3 Cert.Tester No.l�',��;J't;;� Date "�`�• " r�
*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