2017_0705 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 1.D. # 0570040
(Customer) ��� 1
MAILING ADDRESS: ��� Ei�7 S
CONTACT PERSON/PHONE: r
LOCATION OF SERVICE: c � 1'> �
The backflow prevention assembly detailed below has been tested and m ' ned as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
R uced Pressure Principle Reduced Pressure Principle-Detector
ouble Check Valve Double Check-Detector
PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer��(%/(�[�--� Model Number ���G j Size � �
Located At�4'Lt J` �O�/ Serial Number � ,� � T�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��
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��+3psid Held at aC jpsid Opened at Opened at Held at
Initial Test Closed Tig �� 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 Opcned at Held at
Repair Closed Tight Closed Tight psid psid psid
' / / � r �-J �
Test gauge used: Make/Model w� / � �� SN: � il�'3�T ��
Date Tested for Accuracy: �� �C-� � � �
Remarks:
The above is certified to be true at the time of testing.
f f �
FirmName �I �����'��� Firm Address '(9 �('� � .S� r • ���'►{
Certified Tester(pr�nt) �,��� �Certified Tester(signature ��'---�".-��-�� ��'���"���
Firm Phone • C- �� g���Cert.Tester No� ��.�� � 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