2016_0118 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:
CONTACT PERSON/PHONE: QO— C7
LOCATION OF SERVICE: �] �,�t���''I�1�I GjD[.1.h
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
-iReduced Pressure Principle f 'Reduced Pressure Principle-Detector
,�f$ouble Check Valve C Double Check-Detector �
�IPressureVacuumBreaker i�Spill-Resistant Pressure Vacuum Breaker
` I 1
Manufacturer���0 Model Number `�5 Q Size F
Located At � � Serial Number /7 �� � //d 1
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? -2
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�-�Q��� Held atz psid Held at Z�Z p id Opened at Opened at Held at
Initial Test Closed Tigh �� Closed Tight ��. psid psid psid
����,� Leaked'.�1 Leaked�l Did not open I�I Did not open I '� Leaked 1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightC; ClosedTightC: psid psid psid
Test gauge used: Make/Model/���� ������'KSu SN: 03/�(� �(0�
Date Tested for Accuracy: LJ`���l�
Remarks:
The above is certified to be true at the time of testing.
Firm Name<-,Gfl��f/�`{'�Y�"/��Firm Address����//�l�,���S ,��r
Certified Tester(print) � V � ( Certified Tester(signature
Firm Phone#�,�o�'�� ` ��(�Cert.Tester No. 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