2016 y If�RIGATION , �` 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: d.� m�y �-�--� ✓ e--
LOCATION OF SERVICE: 'r`�� �`j c[J�`1 �vl�/"�el
The backflow pre�ention assembly detailed below has been tested and maintained as required by
commisaion regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle �Reduced Pressure Principle-Detector
,��Double Check Valve � 1 Double Check-Detector
C7PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
� ii
Manufacturer ��,1��L`� Model Number ��'�� Size
Located At ��u^r� ' � v'Y�-���� Serial Number ���/ �l � �.i a�
Is the assembly install d in accordance with manufacturer recommendations and/or local codes? `
Reduced Pressure Princi le Assemb] Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve ���
1 st Check 2nd Check
Held at�p id Held at��� p ' Opened at Opened at Held at
I ial Test Closed Tighty� Closed Tigh I psid psid psid
� �� �� Leaked�] Leaked�l Did not open [� Did not open I �� Leakedl
Repairs/
Materials
Used
Held at psid Held at psid �
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight��l psid psid � psid
r � /�
Test gauge used: Make/Model, �j����' ��llc�t����/�.S �� SN: l/ �f�� �< �
Date Tested for Accuracy: J'"f Q`�`�
Remarks:
The above is certified to be true at the time of testing.
/ �" ��'`� � �/
Firm Name L�/�'S�G�� .L—�'��qi�T1�i'1 Firm Address / U�� �tf'� r7�.5 ����
a ��Cerrified Tester(print .fi ,e� � Dhr+ Certified Tester(signatur���-r.__ `�1 _
9 �� ��-----7
,,r L; �����--
Firm Phone#'"!�pt� �,�a��- ��a�� Cert.Tester No�.1!" >� ' t�X� Date
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- Ciry Copy � Yellow-Customer Copy Pink-Tester's Copy