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: �� 33 �'� T S�� D � CO ��-t 1 1 �
CONTACT PERSON/PHONE: �1 Z, �7 � C 2a
LOCATION OF SERVICE: I3 3) L�c T-f�d-c, P�` ��'a t �� 1�x
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
�b*Double Check Valve i�Double Check-Detector
C PressureVacuumBreaker 1Spill-Resistant Pressure Vacuum Breaker
Manufacturer W u l K ��S Model Number ��V Size Z ��
Located At r�. _ � (j� ��*t� Serial Number ���3 Z 3
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y�S
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�Q psid Held at�psid Opened at Opened at Held at
Inirial Test Closed Tigh� Closed Tight fy( psid psid psid
Leaked��I Leaked�.��l Did not open I � Did not open � I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight L'� Closed Tight C 1 psid psid psid
Test gauge used: Make/Model In!�T� Tt�s .S SN:�� I �� �6 �I
Date Tested for Accuracy: Z.- I�— t t
Remarks:
The above is certified to be true at the time of testing.
Firm Name �, v�� �-CG �•••-�-�-+.,.�..�1�tr IFirm Address � �S�-( o �i w�o �-9 nv�,�t w S T X
Certified Tester(print) 1j�,,�,.,..,S c.«�e. �.,,�,Jrertified Tester(signature) ���.��. �-�^-�- ��1 vvH,
Firm Phone#�_t N 3�(I q 3 o J Cert.Tester No. B f QO�43 SS Date � `S" �6
* 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