2017_0712 IRRIGATION V DOMESTIC FIRELlNE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Custolner) � �
MAILING ADDRESS:
CONTACT PERSON/PHONE: �oC,Q. (�eto� �3'38—�i�1
LOCATION OFSERVICE: �2�7 rrlwlofl0�
't'he backflow preventian assembly detailed helow has been tested and maintained as required by
commission regulations and is certified to be aperating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle Reduced Pressure Principle-Detector
+�''boubleCheckValve Double Check-Detector
Pressure Vacuum Breaker -Spill-Resistant Pressure Vacuum Breaker
Manufacturer �{���'n S Model Number ��'j Size�_
L�cated At �l- �/�r� Serial Number A�o�3135g
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? L L5
Reduced Pressure Princi le Assembl Pressure Vacuum f3reaker
Double Check Valve Assembly
Relief Valve Air Inlet C'heck Valve
I st Check �nd Check
Held at�� psid Held at aZ�a"'psid Opened at Upened at Held at
Initial Test Ciosed Tight✓ Closed Tight "� psid psid psid
Leaked Leaked Did not opcn I�id not open Leaked
Repairs/
Materials
Used
Test After Held at psid Held at psid n�ened at Opened at Held at
Repair Closed Tight Closed Tight psid psid psid
T'est gauge used:Make/Modei_��'X�CO �aQ� T1�SU $N; Q�}•OS(7'j�
Date Tested for Accuracy: ((�'��� �O
Remarks:
The above is certified to be true at the time of testing.
FirmName L�LV� 1--r�TfU��^ Firm Address ��� �Y
Certified Tester(print) �uG 12 ��� Certified Tester(signature)
Firm Phone# ' �� _Cert.Tester No.����_Z-_Date '7��Z-� 1–]
* TEST RECORDS MUST BE KEPT FOR AT LEAST TI-IREF,YF,ARS
**USE(JNLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customcr Copy Pink-1'ester's Copy