2016_0113 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)
MAILING ADDRESS:S/'���l'rLA !/Z f� J�61��r,
CONTACT PERSON/PHONE: �
LOCATION OF SERVICE: 6 / E
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�1Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
,�ouble Check Valve ❑Double Check-Detector
�PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �Ji�i �l�rrS Model Number �,�O Size
�
Located At �-/���yiQ-� Serial Number � ��l �5 �
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
1 st Check 2nd Check
Held at��psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�l Closed Tight I '�� psid psid psid
Leakedf 1 Leakedl I Did not open ' ��� Did not open I�1 Leakedi ���
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'-J Closed Tight �1 psid psid psid
Test gauge used: Make/Model����0 �tO-.Za�Ti�✓ SN� �0� �� g 7
Date Tested for Accuracy: 9 / /�S�
Remarks:
The above is certified to be true at the time of testing.
Firm Name `�� -�� Firm Address l���o� �i4S�s/�L'ti ��C'/�� �
Certified Tester(prs nt)y�i�l�R�� �2��Certified Tester(signature}.��� �i�
Firm Phone#�7oZ- l�'' �J—.3 �3�-/ Cert.Tester No. �5 90 Date � �3 �
* 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