2016_0113 IRRIGATION l� 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: ,����-�L� �-�� ���G /,��-�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � /� L�E'�/ �Oc�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�!Reduced Pressure Principle �IReduced Pressure Principle-Detector
�1DoubleCheckValve !Double Check-Detector
lPressureVacuumBreaker f-�Spill-Resistant Pressure Vacuum Breaker
ManufacturerCe�i��z rr✓� Model Number 3.5�0 Size /
Located At ���'�'��i¢s'ld Serial Number � �a�5 �o �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? v�S
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�' � psid Held ata- a psid Opened at Opened at Held at
Initial Test Closed Tight��l Closed Tight I J psid psid psid
Leaked�.��1 Leaked��� I Did not open f I Did not open J Leaked'�� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight' I psid psid psid
Test gauge used: Make/Model C'G��Ca 44��o��hv SNUI�`���� 7
Date Tested for Accuracy: � / !!S�
Remarks:
The above is certified to be true at the time of testing.
FirmName �� ,��� Firm Address�G�� ���t/�ls=�� s�C�SC r�
Certified Tester(pri nt)yYt e c d�9�Gl, ��Q�i C� Certified Tester(signatureL�����.,���G�
Firm Phone#9�a 9�-373� Cert.Tester No. 8S�oil� Date� /3 /JSo
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS �
White-City Copy Ye11ow- Customer Copy Pink-Tester's Copy