2016_0225 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
Ma1iiNG a���ss: 'I �I G�`�, �• �� �1 (� -T0�
CONTACT PERSON/PHONE: � � " �
LOCATION OF SERVICE: � f-- M
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
�bouble Check Valve ❑Double Check-Detector
�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��^�S Model Number �D�� d��v Size
�
Located At £�'e— �`S-t� '1`00� Serial Number d�— �US'1
Is the assembly installed in accardance 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
���`�JIb Held at �'� psid Held at -l�� psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight�' psid psid psid
Leakedi 1 Leaked❑ Did not open ❑ Did not open Ci Leaked�-1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model �/V� �I,.y SN: u�I�.���,1
Date Tested for Accuracy: �.'�' ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name � � ��145 ���e- Firm Address �"N( ����Q��� ��• ���� ��^�RS��'������
�]b���
Certified Tester(pr�nt)��� !"i �v-�� Certified Tester(signature) �� �
Firm Phone# �`� .l.-d� a"l�� Cert.Tester No. q\ 6�5����� Date � ���'r��b
* 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