2016_0229 • �`�;� �_,_ � . ...'�;
� � IRRIGATION /� DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated oTiginal
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: � n �
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
�1Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve I �Double Check-Detector
CPressureVacuumBreaker CSpill-Resistant Pressure Vacuum Breaker
�y 1�
Manufacturer ���bC.E� Model Number Z��� Size�_
Located At � �� � ��'` Serial Number � � �����
Is the assembly installed n accordance with manufacturer recommendations and/ar local codes?
Reduced Pressure Princi le Assembl Presst�re Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at� sid Held at Z• ( si Opened at Opened at Held at
itial Test Closed Tight+� Closed Tight. psid psid psid
��, �� Leakedl I Leaked❑ Did not open C Did not open I I Leaked��� I
Repairs/
Materials
Used
Held at psid Held at psid �
Test After Opened at Opened at Held at
Repair ClosedTight��_� ClosedTight l psid psid psid �
Test gauge used: Make/Model � '� ( C �U� � � SN:�?-?1/�i� �((��-
Date Tested for Accuracy: � I f�!l �
Remarks:
The above is certified to be true at the time of testing. � � �
Firm Name L/ �S/�P -l� �i t� Firm Address G��J +�'i nl �
)
' Certified Tester(print) �G��' � o1�lP Certified Tester(signature) ---
r
�
Firm Phone#��/�?���.�' � Cert.Tester No �J � 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