2016_0305 IRRIGATION DOMESTIC i� 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 LD. # 0570040
(Customer) � ��
MAILING ADDRESS: SD
CONTACT PERSON/PHONE:�' �� �
LOCATION OF SERVICE:
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
f�i duced Pressure Principle f Reduced Pressure Principle-Detector
ouble Check Valve '����Double Check-Detector
I �PressureVacuumBreaker ` ���Spill-ResistantPressure Vacuum Breaker
Manufacturer ��`�--1���� Model Number Q� Size �_�
Located At fi�re �w�.� f dp'W� Serial Number j� �y'�G1#�
Is the assembly installed in accordance with manufacturer recommendations and/or]ocal codes?
Reduced Pressure Princi le AssembL Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air[nlet Check Valve
1 st Check 2nd Check
� Held at__psid Held,at psid Opened at Opened at Held at
Initial Test Closed Ti t�.1 Closed Ti t ��I psid psid psid
Leaked� � �� Leaked'�� � Did not open ' � Did not open i I Leaked��� !
Repairs/ .¢,��Q�•�� 1 �GtCP
Materials �. � C�� �
Used C�e,�,
Held at �� psid Held at 1�� psid
Test After �� Opened at Opened at Held at
Repair Closed Tight � Closed Tight � psid psid psid
Test gauge used: Make/Model 41��(-��.�5 ��S sN: n�t��a9�
Date Tested far Accuracy: � -�'� ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name���L �[�.A'l Firm Addres .�� ~CIQ.Y' Ji-. C�Y� r�"-��t+� ��'��
Certified Tester(print)J� Certified Tester(signa -r
Firm Phone#��eZ'��'�G� Cert.Tester No.�f�O l�t(0 3 f Date ���� l(p
* 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