2017_1031 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) 1
MAILING ADDRESS: i 303 G�ra�r�. lef C�� � 21��x
CONTACT PERSON/PHONE: v�`d �.� `��y — �`+V
LOCATION OF SERVICE: �l� �i n�a D�`v�
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
�1Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer
�'�S Model Number�T�( 1�� �T Size ���
Located At �T`p'1� O� �Ct"�ot�� E�G� Serial Number O� �J y"�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � �S
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 Z�Z psid Held at 3�`�' psid Opened at Opened at Held at
Initial Test Closed Tight'� Closed Tight f� psid psid psid
Leakedf ] LeakedC� Did not open �1 Did not open ��� Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight f i psid psid psid
Test gauge used:Make/Model �� �'�` Z� ��— SN: ZS�Onb
Date Tested for Accuracy: ����/ 7
Remarks:
The above is certified to be true at the time of testing.
FirmName �- �� � �S� Firm Address ��v �� ��►� �P��l
Certified Tester(print)�V�C� I� Certified Tester(signature) �
� Firm Phone# 2�'f —`C�L $� t� Cert.Tester No. kJ��'1F?/7�3 Date D 3 j��7
* 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