2016_0114 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 PW� ITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS: �S� ` � O'Q j'��,I_
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: ,�� _
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
7Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
��•vl,�ubleCheckValve �uble Check-Detector
-1PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer�,�'Se,Qi) Model Number �,��,�_Size �
Located At�I�,Qme,�/ yi�b�p GY1 �QMQ,'�' Serial Number �B(�q�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e
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 psid Held at psid Opened at Opened at Held at
Initial Test Closed Tight❑ Closed Tight � psid psid psid
Leakedl I Leakedf 1 Did not open 'l Did not open ':=1 Leaked❑
Repairs/ —�-�^�
Materials "�"r ' S�.U'� �'F V0.��f. �QGIC�i��' ►�L��G( / � �,.•��Q,�
Used � �,�,� ,�
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I ! Closed Tight�� psid psid psid
Test gauge used:Make/Model�/19��(,�t�S� 7 SN: �b�?�S� �P
Date Tested for Accuracy: ]���3—/�
Remarks:
The above is certified to be true at the time of testing.
Firm Name /�� �`r2. �' �Dw�e�fi� 1G�f7,��rm Address��• X 7fS��� �f"�iV`�"f'l,,%)C 7(�0 %�
Certified Tester(print �r� Certified Tester(signature
Firm Phone# �i I?'a�,a'�S� �7 Cert.Tester No.� J�����3$ � Date j
* 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