2016_0215 IRRIGATION_� DOMESTIC FIRELINE
The following form must be completed far each assembly tested. A signed and dated original
must be submitted to the public water suppYier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: �Lv� yYl, � „e� �?"j�-7��Sz�-
LOCATION OF SERVICE: �(�3 �;��,�,,,�, lf-
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
y�Double Check Valve ❑Double Check-Detector
��PressureVacuumBreaker �Spi11-Resistant Pressure Vacuum Breaker
Manufacturer /"f�v Model Number �✓�� Size /��
Located At �� /���� ��,.,� ��� Serial Number �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �f�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
lst Check 2nd Check
Held at ��lJ psi Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight �.- �psid psid psid
Leakedf 1 Leakedr'I Did not open ' 1 Did not open i ' Leaked' I
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 � �lv�ii,`� SN: �l/����
Date Tested for Accuracy: ��/f
Remarks:
The above is certified to be true at the time of testing.
Firm Name G��/ ,' , Firm Address � G,, ,�
_ h/ /s.i �
Certified Tester(print) Certified Tester(signature)
Firm Phone# �`/7�—�j��2�i�•J Cert. Tester No,Q�I/��►-�y- Date ��f��
* 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