2016_0121 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 far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) ,.1
MAILING ADDRESS: �3�3 W!'Q 1Q� �',�. Co eI J, 7SO
CONTACT PERSON/PHONE: ' � .�/ - — D�f0
LOCATION OF SERVICE: C�rS o�-� -
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 7Reduced Pressure Principle-De�ector
���oubleCheckValve � IDouble Check-Detector
1PressureVacuumBreaker :;.Spill-Resistant Pressure Vacuum Breaker
, 1- Q i�
Manufacturer (�JC!�S Model Number f�9 m � Size �Z
Located At Serial Number `�.�7���
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �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 at ��� psid Held at psid Opened at 3•`f Opened at Held at
Initial Test Closed Tightl � Closed Tight �"�1 psid psid psid
Leaked I I LeakedCl Did not open I�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 ClosedTight'� I � ClosedTight�I psid psid psid
Test gauge used:Make/Model�M�v0.�-v '�'U'Z�bT�L SN: ZS SOC��
Date Tested for Accuracy: ___q//�'I/J
Remarks:
The above is certified to be true at the time of testing.
ei 1�5� �
FirmName �(�p Firm Address �n.3 �R� ✓ 1�
Certified Tester(prsnt) � � � Certified Tester(signature) �
Firm Phone# 2������� Cert.Tester Na ���75 Date � ,2 (
* 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