2016_0211 IRRIGATION ✓ , DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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 I.D. #0570040
(Customer)
MAILING ADDRESS: -Jrp 5$ ���pT �,�=,����� �� ������—j5��
CONTACT PERSON/PHONE: ►-{��y -Z n�i�
LOCATION OF SERVICE: i O 1 �,.��a�u�e�
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 !�Reduced Pressure Principle-Detector
I�ubleCheckValve C�Double Check-Detector
�PressureVacuumBreaker f ISpill-Resistant Pressure Vacuum Breaker
Manufacturer 1,��,Pc�lTS Model Number (�D�1 M 1 C�'�Size o�'�
Located At�� (�,� �� ��� c�n l,�rat�i IcfSerial Number � � '�
�-d .
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �C S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air lnlet Check Valve
1 st Check 2nd Check
�SS Held at�psid Held at rQ•o�sid Opened at Opened at Held at
Initial Test Closed Tigh ��� Closed Tight - psid psid psid
Leakedi I Leaked�l Did not open 1 Did not open [.1 Leakedl�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i 7 Closed Tight C� psid psid psid
Test gauge used: Make/Model t,�,� �k.`�nt �(7� SN: (���2�y-��
Date Tested for Accuracy: 1-(-{� -[S
Remarks: una4,►e .� f � �Q�'i�( (1�m��� �'j�r!v
The above is certified to be true at the time of testing.
FirmName��p� �r� Firm Address�ql /ar,Q� y. ;e {3� X�, FT�GvI��('1jC�lI(�
Certified Tester(pr3nt�f'Giuj��t� Certified Tester(signature)�,�IC,Z.Ir����
Firm Phone# 9(�--�-��3 Cert.Tester No. (�P(7�7i y(��[3 Date a-!I-)�
* 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