2016_0307 (2) IRRIGATION � DOMESTIC FIRELINE
S�.
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: � V A-
CONTACT PERSON/PHONE: - " lp
LOCATION OF SERVICE: � �� � � ('��
The backflow prevention assembly detailed below has been tested and maintained as required by �,(,btZ I 1,�
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
R ced Pressure Principle 7Reduced Pressure Principle-Detector
oubleCheckValve IDouble Check-Detector
:-1 Pressure Vacuum Breaker I Spill-Resistant Pressure Vacuum Breaker
Manufacturer �2/� C�i'� Model Number (�`��'f7 Size � 11
Located At Serial Number������
Is the assembly installed in accordance with manufactu er recommendations and/or local codes?
��r�� 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.�'lP psid Held at�-�psid Opened at Opened at Held at
Initial Test Closed Tigh � � Closed Tight - psid psid psid
Leaked i 1 LeakedCl Did not open I 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'_7 ClosedTight f psid psid psid
Test gauge used: Make/Model 1ti1 G� � ���,- C� a b c� SN: �3,�_____�_J jo_�
Date Tested for Accuracy: ���L�`
Remarks:
The above is certified to be true at the time of testing.
Firm Name �!�C,�, �L,D kJ �,�.�1�UFirm A ddress �S o� � �" �� O,�
Certified Tester(printk�'�@.(�,� � .�U��ertified Tester(signature)
Firm Phone#��"'��O�� ��-��1. (��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
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