2016_0229 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: ��,,r,�/ S!�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
i-Reduced Pressure Principle ' IReduced Pressure Principle-Detector
�oubleCheckValve -1.Double Check-Detector
1PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
3
Manufacturer �,cJl��j i�^5 Model Number -3 S � Size�
Located At /=/�/r✓/ ti/�-/� Serial Number�Sa ��' 3 �
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�` Y psid Held a�`� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight �- psid psid psid
Leaked' 1 Leaked'� I Did not open .�1 Did not open I '� Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I i Closed Tight[ i psid psid psid
Test gauge used: Make/Model GO'�2 � �ZGz-ar� %Fi,t� SN:� �O�-1 / (o�' 7
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
c /� �^ ^ / ., c--�
Firm Name J/� ,�✓2� Firm A ddress�(2��+ G'9S�✓���i �GIl�S� ��
Certified Tester(pr�nt)��C/�iqG(.. �v2��Certified Tester(signature)����_.f�a��* �G��
Firm Phone#�l`7�2— l�O^ ,3 7a3(�Cert.Tester No._�� �'d DateO� r� �/
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy