2016_0222 �
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: 1 IS I��w k: �N' _ Cir-I�P�L(� , I x. �5��l�(
CONTACT PERSON/PHONE: (�-.�-� �-�Yz.i G v�Z
LOCATION OF SERVICE: 1 I s {-��.4 w� L � �
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�jeduced Pressure Principle -1Reduced Pressure Principle-Detector
�oubleCheckValve -]Double Check-Detectar
f 1PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer ���r��S Model Number Q�l ���1 Size � �
Located At �Rc-+�T ���c S C�.�� I �-��� Serial Number '��(�2� �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y ��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
Held at 2-� psid Held at 2•2 psid Opened at Opened at Held at
Initial Test Closed Tighti� Closed Tight f� psid psid psid
Leaked I Leaked I Did not open I ; Did not open f 1 Leaked' '.
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� 1 Closed Tight�� I psid � psid psid
Test gauge used: Make/Model �e-►.1�,,i�c-rL�J $'1� SN: 11"9�6`����3
Date Tested far Accuracy: 1 � � 2-(��
Remarks:
The above is certified to be true at the time of testing.
FirmName A-q-.� q�fiv� I�i�F�u�w Firm Address INI� �r��Y �¢..�`��3 ��z.+�ai.�-t�� v�- 75��)
Certified Tester(pr:nt)�,��tii� C�FiFn•�t� Certified Tester(signature) ��"�.����
Firm Phone# 9� l��'�'Z-2ZZ`� Cert.Tester No. �`oL�1 53t�C� Date Z 22 � ��
* 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