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) ,Q
MAILING ADDRESS: ���yv,c7lq-/�iO / A-Gl l�'L '012��j
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � ,, ` [ G-_
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
�oubleCheckValve lDouble Check-Detector
�PressureVacuumBreaker � 1Spil1-ResistantPressureVacuumBreaker
Manufacturer 4/��ftl�S Model Number 3,`J� Size�
Located At ��P''��%/4'�L� Serial Number
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 a��3 psid Held a�-� psid Opened at Opened at Held at
Initial Test Closed Tight'.� Closed Tight f psid psid psid
Leaked'��; Leaked�' Did not open .��1 Did not open I 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 I I psid psid psid
C�[�!lfLO
Test gauge used: Make/Model �-+�'���5 �i0 �� �� V SN�CJ d�'/ �� g �
Date Tested for Accuracy: �!!���
Remarks:
The above is certified to be true at the time of testing.
FirmName �� -���� Firm AddressGG���s/v�� ���� ��
Certified Tester(pr�nt)�►C�j�s9(>�- �,f/,h[� Certified Tester(signature�!i�.�uf'��`{���_.
Firm Phone#�1,�— �������3�J Cert.Tester No. �S'�'4 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