2016_0505 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 I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: ' �v� ����� ��
LOCATION OF SERVICE: , �n��I I
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 CReduced Pressure Principle-Detector
�oubleCheckValve �1Double Check-Detector
-�PressureVacuumBreaker �Spi11-Resistant Pressure Vacuum Breaker
Manufacturer I�L� Model Number ��� Size�_
Located At �V �f1�P� Serial Number �� ���`�o`
Is the assembly installed in accordance with manufacturer recommendations and/or 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�2.Z psid Held at 2•� psid Opened at Opened at Held at
itial Test Closed Tight������ Closed Tight psid psid psid
� Leaked�� Leakedi�1 Did not open C'� 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 I � Closed Tight I�I psid psid psid
Testgaugeused: Make/Modely}{Jf�,�p T�o�-�TK�U SN:�3/�� (D ,p`i-
Date Tested for Accuracy: '"��"��
Remarks:
The above is certified to be true at the time of testing.
Firm Name SfC�P ' Y'/QC.� /r�/�Firm Address Jr�� h����(�(����r/)�5 �IF•
� Certified Tester(pr�nt)� dI'1� Certified Tester(signature)
Firm Phone#�,�� �D�� �d c��C Cert.Tester No g 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