2017_0627 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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: C S I Gc��S��l-� ✓�=�
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
' PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
� c�
Manufacturer(��L„� t�r�� Model Number �;�0 Size
Located At !''�i'r%� Serial Number� �S�'�,3 �j�
Is the assembly installed in a cardance 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 a�• 'Z psid Held a�` � psid Opened at Opened at Held at
Initial Test Closed Tightr�� 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_7 Closed Tight�� psid psid psid
Test gauge used: Make/Model ��'i/�LJ9--C.t� ��'a� `�I t� SN:�C���'I l �o � �
Date Tested for Accuracy: �.���r(s
Remarks:
The above is certified to be true at the rime of testing.
Firm Name S� .�-��� Firm Address�c�o�o��S1r/i C�-✓ ���7'$G ��-
Certified Tester(print)y1�1�CL�q--�-�r^'y��=Certified Tester(signatu .-
Firm Phone#�7� Q1�'G--.�7 3 �J Cert.Tester No.G� s�l'�'j 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