2016_0107 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 supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) p
MAILING ADDRESS: � ��'�-yc�Jr4-�l�D p��-G/F�L /�.�n�S
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �o � L��•Q/��G�
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
1Reduced Pressure Principle 7Reduced Pressure Principle-Detector
�'Double Check Valve C Double Check-Detector
❑PressureVacuumBreaker I 1Spill-Resistant Pressure Vacuum Breaker
Manufacturer �lG,�'�/ti5 Model Number 3s0 Size `7�
Located At �/1F/� t,//��� Serial Number j�} .� a 7�/J/
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 a��D psid Held at ?•�psid Opened at Opened at Held at
Initial Test Closed Tight��,i Closed Tight � I psid psid psid
Leakedl�'��� Leaked�� Did not open I. I Did not open ���I Leakedl�1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight L] ClosedTight�I psid psid psid
Test gauge used: Make/Model�O�tb[�IGp 4'G a?�D / f'lr SN:�C�G� ! (0 9 �
Date Tested for Accuracy: g �/ �i '�
Remarks:
The above is certified to be true at the time of testing.
FirmName s� ��� Firm AddressGGaa��slv��w ,S/�CyS� T,t'
Certified Tester(pra nt)y1'J�el�rg�L /3(,Q�l� Certified Tester(signature��//—�i�/ GGc,�f _ ��
Firm Phone#qyo� 9�-373LJ Cert.Tester No. �5 �D 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