2016_0205 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) I � �
MAILING ADDRESS: l� �� �
CONTACT PERSON/PHONE: .� - �
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 I � �
"�
�Reduced Pressure Principle C�Reduced Pressure Principle-Detector � �� �
�Double Check Valve ❑Double Check-Detector �� �
❑PressureVacuumBreaker f 1Spi11-Resistant Pressure Vacuum Breaker � '-
� �i
Manufacturer�j��� ��5 Model Number � Size �
Located At —����� � ri 1 m r S �
Se a Nu be 33� � �j�j7g ( 1,��
Is the assembly installed in accordance with manu a rer recommendations and/ar local codes? — ���v_
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
� Relief Va Air Inlet Check Valve
1 st Check 2nd Check
2
Held at�� psid Held at 3 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leakedf I Leakedn Did not o n ❑ Did not open '��1 Leaked'��i
Repairs/
Materials
Used
Held at psid Held at psid
Test After O ened at Opened at Neld at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used: Make/Model S � SN: �'t�� ��3�
Date Tested far Accuracy: Z �d
Remarks:
The above is certified to be true at the time of testing.
��Firm Name � � rm Address Z C�V ..�
Cerrified Tester(print)� � � Certified Tester(signature) ������
�
Firm Phone# �/��`�.S �g�� Cert.Tester No. �3'�� Date �
��
* 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