2017_0608 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) n /�
MAILING ADDRESS: (�p3 W 1�ar�e" l�;r l�aOel� �X
CONTACT PERSON/PHONE: �--out5 r►'�a���s � 2��t-4q�- Sv4n
LOCATION OF SERVICE: I 3U3 t,�ran� �`r �DPeCI '—r?C
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 �Red�iced Pressure Principle-Detector
� I Double Check Valve 'Double Check-Detector
! I Pressure Vacuum Breaker -�Spill-Resistant Pressure Vacuum Breaker
Manufacturer �4��5 Model Number �--Fv��l ��'1 Size ���-
Located At�ood �7e,-vie�� i�orq�tG Serial Number �OC���(a
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
Q r7S Held at ?�� psid Held at psid Opened at Z�ro Opened at Held at
Initial Test Closed Tight� i Closed Tight �1 psid psid psid
Leakedl I Leaked! i Did not open I Did not open ' Leaked '� �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight' ! ClosedTight I psid psid psid
Test gauge used: Make/Model �r''����-n �fl'�'� � k SN: Z`��v�
Date Tested for Accuracy: �''1 �� � ��
T
Remarks:
The above is certified to be true at the time of testing.
FirinName ��pP� � -I—S� Firm Address �?J�� leY' �►� � �� �
Certified Tester(pr�nr)���i�w ttn�t�C� Certified Tester(signature) � _
�
� 9 �P�� -�jg Date � ��
Firm Phone# ��`�" "� L—�D�}6 Cert.Tester No.
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REFLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy