2017_0612 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 REPOKT
NAME OF PWS: CITY OF COPPELL PWS LD. #0570040
(Customer) p
MAILING ADDRESS: ��� ' 1� or I �a�� . � 1( ��� y
CONTACT PERSON/PHONE: 1/��c Q w( - �h s f�l!Q t' �S I u�,ti ��.z�' �� �-ao g O S 3�
LOCATION OF SERVICE: ,30� �Y�c� �`c� P(atQ � �o_O,o�,� �sO �Y
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
:�uble Check Valve ��Double Check-Detector
�PressurcVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
f�� l �
Manufacturer W r ���5 Model Number 3�d Size
Located At �Q-r�--� f� � Serial Number � � 1� `r� 3 .
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? l�,S
Reduced Pressure Princi le Ass rnbl Pressure Vacuum Breaker
Double Check Valve Assembly '
' Relief Valve Air Inlet Check Valve
1 st Check 2nd Check ��
, _.---2 r.—�.
� Held at�'> psid Held at � �psid Opened at Opened at Held at
Initial Test Closed TightU� Closed Tight � psid psid psid
��j5 Leaked. Leaked.7 Did not open ' Did not open Lcaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight��� ' ClosedTight l_I psid psid psid
r
Test gauge used: Make/Model �6r�cco �fD-v�0o � T�S sN: o rQ a�2� �
Date Tested for Accuracy: �� a 3(((v
Remarks:
The above is certified to be true at the time of testing.
FirmName ,o�� ��{ �ay�G���l�'' �e�,Firm Address �yl� �l'���ii.-e. �� � ��l,P,y, � /'� � �v,�,�
Certified Tester(print)�Srae� �q nn,�eT� Certified Tester(signature) �/���C�
Firm Phone# a f�-���' ��(l 5� Cert.Tester No. ���'°l���5 Date � l!J l7�
* 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
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