2016_0502 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• ��f'��f i�P �12.7���%
LOCATION OF SERVICE: �/U �/�il�/�
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 '1Reduced Pressure Principle-Detectar
�oubleCheckValve ��� 1Double Check-Detector
ressureVacuumBreaker �'�Spill-Resistant Pressure Vacuum Breaker
� ` �//
Manufacturer ��G�v Model Number ��� Size
Located At °� ���i Serial Number �t✓ / ���
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �t�
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 Tight� Closed Tig t f �cl � psid psid
Leakedf�l Leakedn Did not open f I Did not open I I Leakedl 1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�l Closed Tight C'� psid psid psid
Test gauge used: Make/Model�,d�,f/U �UZL�/��,5/J SN: �',1�UvrJG�l"
Date Tested for Accuracy: s�/�/�
Remarks:
The above is certified to be true at the time of tesring.
FirmName � J � Firm Address��� !—,�/� ,ei��,��
Certified Tester(pr�r�t) �G/ .� Certified Tester(signature)
Firm Phone#�l���1�-��li�r/ Cert.Tester No. �1�Ud�Y'���f 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