2016_0121 IRRIGATION DOMESTIC t/ 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: � 3 03 W f�f1 l—i r' � �
CONTACT PERSON/PHONE: ' ' — -Sa0
LOCATION OF SERVICE: ' L,�1
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 C7Reduced Pressure Principle-Detector
❑DoubleCheckValve ❑Double Check-Detector
rlPressureVacuumBreaker f,Spill-Resistant Pressure Vacuum Breaker
Manufacturer 1/�UI,T�S Model Number 9 og rn � Size I ��'Z
Located At �� ��u, Serial Number '�35 S��
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 i Z psid Held at psid Opened at 3�'� Opened at Held at
Initial Test Closed Tight�d, Closed Tight L-1 psid psid psid
Leakedf 1 Leaked❑ Did not open I 1 Did not open [] Leakedl !
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight��_J ClosedTight� psid psid psid
Test gauge used: Make/Model �M IpYi0.C.D �0^ZOD� SN. ZSSQ��
Date Tested for Accuracy: Q��8��c5�
Remarks:
The above is certified to be true at the time of testing.
n_ r �" /• ' n 1�
FirmName W��el I —L�D Firm Address ��3 W ��-�
�, �
�
Certified Tester(pr:nt) Q C� Certified Tester(signature)
Firm Phone# 2�T' ` I� �U`'Cd Cert.Tester No. Date � r��` �
* 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