2016_0504 IRRIGATION V 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: �L��,np'�ES► L.,-1� �C'�a�q, Qne �er.,�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: /�S s: Qti,��h Te� d, C'goo�l I � TX '1S0/9
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
►�educed Pressure Principle IReduced Pressure Principle-Detector
I Double Check Valve �� �Double Check-Detector
I� ���Pressurc Vacuum Breaker � �Spill-Resistant Pressure Vacuum Breaker
ii
Manufacturer �✓i�ki n r Model Number � 7 S Size�_
Located At �'/rI�,-FN' a'{'�n f'+e�scc'E-�o n Serial Number /� Y/S'9�s
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? c S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
5�� ��� Held at � �'/ psid Held at �. Q psid Opened at 3• Z Opened at Held at
initial Test Closed Tight�� Closed Tight F�h� psid psid psid
�q Ss� Leakedl I Leaked' I Did not open �. 1 Did not open I I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opencd at Opened at Held at
Repair ClosedTight�1 ClosedTight I psid � psid psid
Test gauge used: Make/ModelCe h fj�a �� yn—�oo—TK SN: 3$/3 S�
Date Tested for Accuracy: / /Z'7 �/ [�
Remarks:
The above is certified to be true at the time of tesring.
FirmName Cusl—ew, �/en'�'�er�t_ T., �Firm Address PO $o x 7. Pa r�.�TTjr '7SSi6 �
Certified Tester(pri�r) �C I�r y ��,�,�hCertified Tester(signature) `
Firm Phone# �03—�}qS-�1 3 9 Cert.Tester No. 8P Q o 13'7$�_Date �$��i///Ce
* 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