2016_0302 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 LD. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: ✓.(� ���►-�� ✓-�
LOCATiON OF SERVICE: �5�I�_�L�U t"�1 CoD�e.I j
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
�]
duced Pressure Principle '��Reduced Pressure Principle-Detector
Double Check Valve '1 Double Check-Detector
I ��PressurcVacuumBreaker f 1Spill-ResistantPressure VacuumBreaker
I ii
Manufacturer ��C.1`� Model Number ��� Size
� ,/ �
Located At D �'� � VY��'�4.✓ Serial Number ►1� �� U a�J
Is the assembly install d in accordance 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�p id Held at�'� p ' Opened at Opened at Held at
1 ial Test Closed Tight� Closed Tight� psid psid psid
� �,� Leaked' I Leaked.I Did not open I�� 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'i1 C]osedTight. I psid psid psid
Test gauge used: Make/Model • , B�`p ��1� ,I��� SN: (/3�Q���
Date Tested for Accuracy: 5'� �'��
Remarks:
The above is certified to be true at the time of testing.
Firm Name
.��/� _��'!�l Ci dY� Firm Address /` Q`� '�� h V./�
Certified Tester(pr:nt �v� /` oh� Certified Tester(signatu
Firm Phone#%������' ���� Cert.Tester No�� 0 � Date � � � �o
* 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