2016_0510 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 recardkeeping 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: S�3d �l/'�•�G'/L��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
�� IReduced Pressure Principle '� 1Reduced Pressure Principle-Detectar
�ouble Check Valve �� I Double Check-Detectar
IPressureVacuumBreaker :1Spill-Resistant Pressure Vacuum Breaker
Manufacturer l.cJ��.�!'e�vS Model Number �,$'O Size '3�
Located At �20�� //¢� Serial Number �.��� I��
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 ato►�� psid Held at°7�3 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight ?� psid psid psid
Leaked� I Leakedl ' Did not open � Did not open I Leaked'
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTighti�� ClosedTight l psid psid psid
Test gauge used: Make/Model G�1 p Z/U��a�- /�'(J SN:��L( 1 Co C/ 7
Date Tested for Accuracy: g,� /S
Remarks:
The above is certified to be true at the time of testing.
Firm Name .s,� �!� Firm Address Z G;t� EAs N�E'✓ �I�C',�5� �/�
Certified Tester(pr�nt)J'Yjtel(�q€2, �L�1� Certified Tester(signatur��',i������LC
Firm Phone#97�"�9� -373 H Cert.Tester No. ��gZ� Date.S </G /
* 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