2016_0307 IRRIGATION DOMESTIC FIRELINE
The following form must be completed far 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 LD. # 0570040
(Customer)
MAILING ADDRESS: _ S�n---� �
CONTACT PERSON/PHONE: �� �
LOCATION OF SERVICE: O S �_ ��U L'��P
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 �_IReduced Pressure Principle-Detector
1 Double Check Valve ' IDouble Check-Detector
�7PressureVacuumBreaker �1Spill-Resistant Pressure Vacuum Breaker
/ /� / >/
Manufacturer L�'//���� Model Number ���� Size /
Located At �a� � � �� Serial Number � J�3 4� ,g�
Is the assembly installed in accord 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 at 3.�� psid Held at oC•C� psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight � psid psid psid
Leaked�! Leakedl�I Did not open _ I Did not open �_l Leaked�.1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Neld at
Repair ClosedTight❑ ClosedTight I I psid psid psid
Test gauge used: Make/Model � O���r�<<_� sN: 3 y 9� s �
Date Tested for Accuracy: 3��� I.6
Remarks: �
The above is certified to be true at the time of testing.
�—
Firm Name �� (/�/�A� Firm Address .2 SJ L/��� (/��/�4 c�JIP��°�e- �y
� . ? ����8
Certified Tester(pr�r.t)�d���T��•'�� Cerrified Tester(signature)
Firm Phone# �/�f 7I$ �$/�-� Cert.Tester No.�(�J��`��7��� Date � / 6
* 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