2016_0307 � ELINE
IRRIGATION DOMESTIC FIR
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: U � U ^ �
CONTACT PERSON/PHONE: —
LOCATION OF SERViCE: a�'�� f„� , 1 �' �/t��'AUR 4 .]���i� �;, ��
The backflow prevention assembly detailed below has been t�sted and maintained as required by ���-��•�
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
iRe ced Pressure Principle ' IReduced Pressure Principle-Detector
ouble Check Valve ' I Double Check-Detector
I 1PressurcVacuumBreaker ' ISpill-Resistant Pressure Vacuum Breaker
Manufacturer �r L� ' Model Number �� �
� � l� Size�__
so�r� n iZ .� /£ F►GE�Ps4 4 �
Located At /l1J E%I�bN� Ot'� 1�/M Serial N�mber
—.—r--
Is the assembly installed in accardance with manufacturer recommendations and/ar local codes?
�� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
(�J Double Check Valve Assembly
�)I Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at ,. .�psid Held at�psid Opened at Opened at Held at
Initial Test Closed TightF�Y� Closed Tight i psid psid psid
Leaked�1 Leaked�'. 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 Closed Tight f ��� ClosedTight[�.�'� psid psid psid
Test gauge used: Make/Model �'N�C� �''�4 "OD�f SN: ',3�b 7�,3
Date Tested for Accuracy: �� / �e I/� J ha
Remarks: %I��/�►
��
The above is certified to be true at the time of testing.
Firm Name�„Q,���I�tJ �����7F'irm Address F"D- � ��/� J'b � �' 7���,�
� Certified Tester(pr;nt) �C(�1'�4 11 � �n��,`�"�rtified Tester(signature)
Firm Phone#����� � —4 r l�Cert.Tester No. Date �
* 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