2016_0623 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 LD. # 0570040
(Customer) / -�-
MAILING ADDRESS: ��J'r { I�I SD� �J(,��dd
CONTACT PERSON/PHONE: 1 • �5g
LOCATION OF SERVICE:
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
�Re ced Pressure Principle ❑Reduced Pressure Principle-Detector
i ouble Check Valve C IDouble Check-Detector
❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �MtT[� Model Number de7 M 1 Q T Size � �/
Located At ��J�rl rial Number �����'
Is the assembly installed in accorda ce 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�psid Held at �� psid Opened at Opened at Held at
Initial Test Closed TightC� Closed Tight _ psid psid psid
Leakedl I Leaked❑ Did not open ❑ Did not open [J Leakedl�1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used: Make/Model l�� �J l� ( s SN: b� ��3�S�
Date Tested for Accuracy: �a �c�"�
Remarks:
The above is certified to be true at the time of testing.
Firm Name /i�� �/� Firm Address 7� �`��''�A' � �hC ���l�
Certified Tester(print)��'��'G'r"1��� Certified Tester(signatur�
Firm Phone# p�7�dr�"��8� Cert.Tester No.����a! Date CQ Q� l
* 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