2016_0229 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: �7_ �, � iD��' v C.l
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
�;Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
.�oubleCheckValve �Double Check-Detector
C1PressureVacuumBreaker ��Spill-ResistantPressure Vacuum Breaker
!/
Manufacturer �e�L� Model Number ��� Size�
� � �^
Located At � 7� ,�- Serial Number � /�� �
Is the assembly install d in accordance�with manufacturer recommendations and/ar 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�•�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight� psid psid psid
Leakedl I Leaked�l Didnotopen [�; Didnotopen I I Leaked.��l
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight���� ClosedTight❑ psid psid psid
Test gauge used: Make/Model�aD��� �D�OD�KSC.I SN: �' �[�D l�1��
Date Tested for Accurac�: '�`/�"/�
Remarks:
The above is certified to be true at the time of testing.
FirmName ua � /� , T Firm Address�� /v/�l����/�/�l-,S �
Certified Tester(pr�nt oi � Certified Tester(signatur
Firm Phone# g)�- 7i,���f.�� Cert.Tester No Q� �8 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