2017_0925 IRRIGATION x 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: 13 D`3 �U r an 'er ;r Cv e(1
CONTACT PERSON/PHONE: ' i 4- 49 b-- C!y6
LOCATION OF SERVICE: �.�
The backflow prevention assembly detailed below has been tested and inaintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
` iReduced Pressure Principle '-iReduced Pressure Principle-Detector
i?4Double Check Valve !Double Check-Detector
I 1 Pressurc Vacuum Breaker -i Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��lt_p Model Number �SrL' Size � ��ZI
Located At_�rprt� p�- ��qq Serial Number `--�Z��j32—
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 2�� psid Held at Z�`7 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight �� psid psid psid
Leaked'. I Leaked' i Did not open : I Did not open I Leaked �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight' i Closed Tight I psid psid psid
Test gauge used: Make/Model l,-oM�rOlCt� �' Z�'T�SN: ZS�QOD
Date Tested for Accuracy: �'I� ��(� � 1
Remarks:
The above is certified to be true at the time of testing.
Fir�n Name l�LY.'�1 �cJ� Firm Address �,�� �ir �I �
Certitied Tester(pr;nt) ` t� Certified Tester(signature) `
Firm Phone# �j� — ��L" �'�T� Cert.Tester No. �JP���_Date � �S /
*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