2016_0307 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 recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: � r�.,-C
CONTACT PERSON/PHONE: /1�� d� !
LOCATION OF SERVICE: � � � �'�.C2��
The backflow prevenrion assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle lReduced Pressure Principle-Detector
�-1DoubleCheckValve �1Double Check-Detector
C�PressureVacuumBreaker CSpill-Resistant Pressure Vacuum Breaker
� � �/
Manufacturer ����/e�� Model Number � �� Size �
Located At �� � C3���''� Serial Number � �J�C� �� O
Is the assembly installed in accordance with manufacturer recommendations andlor 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 ��C.1 psid Held at �•�psi Opened at Opened at Held at
lnitial Test Closed Tight!� Closed Tight � psid psid psid
Leakedl I Leakedl ! Did not open I I Did not open ��J Leaked�.l
Repairs/
Material s
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight J ClosedTight l psid psid psid
Test gauge used: Make/Model �O�c3�-��> SN: .3 L�� ,8 S�
Date Tested for Accuracy: 3��%�� ��
Remarks:
The above is certified to be true at the time of testing.
f�/C�1 v�m�c / �
FirmName /<oGP2��.9kv,�// Firm Address �.S' ��e? `��15/�° ���'T��y���
� ,�,�'
Certified Tester(print)�d�P�!�?.gc��'�� Certified Tester(signature)
Firm Phone# ��`� ?/.$ 7 Sl o�— Cert.Tester NoI��'���/7�.Z Date 3 � /
* 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