2016_0107 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: �/A�v+9R-�-11 T"�}G�L l�m�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: G�7 /I"/Y ��-N
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
I 'Reduced Pressure Principle f 'Reduced Pressure Principle-Detector
�oubleCheckValve ' ';Double Check-Detector
�PressurcVacuumBreaker 1Spil1-Resistant Pressure Vacuum Breaker
Manufacturer �
���C.p Model Number �S� Size
Located At t��Uri l—i{i9-/LD Serial Number�� a S o� 7-3
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
l st Check 2nd Check
Held at�� � psid Held at ��psid Opened at Opened at Held at
Initial Test Closed Tighti 1 Closed Tight ���l psid psid psid
Leakedf 1 Leaked����I Did not open I I Did not open I ! Leakedl '�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight-I Closed Tight C psid psid psid
Test gauge used: Make/Model m �a`�o`O � h�' SN:O�L(/�C''! �
Date Tested for Accuracy: � / I �
Remarks:
The above is certified to be true at the time of testing.
Firm Name s�� S2 Firm Address�fio?,Z�i4 S�vi Fr� .�i�c'/��= 7�
Certified Tester(pri nt)�?�G � �'�-�/y��L Certified Tester(signature,��/f�t�� ��
Firm Phone##�7���—,3�.3�'/ Cert.Tester No�S �!� Date l 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