2016_0517 �
IRRIGATION DOMESTIC FIRELINE
The following form must be completed far 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 l.D. #0570040
(Customer) / -�—y
MAILING ADDRESS: �y� CI''Af� G�-n . �op�ell , /�i
CONTACT PERSON/PHONE:/�eSi�P�1 f
LOCATION OF SERVICE: 5`f�'/ (��A/.P 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
-�] duced Pressure Principle C Reduced Pressure Principle-Detector
ouble Check Valve C;Double Check-Detector
-�PressureVacuumBreaker f iSpill-Resistant Pressure Vacuum Breaker
,i!
Manufacturer�b(`D Model Number g`jD Size
Located At �✓0�►� d� h ovle �� �Il��� �'D j(Serial Number E� ��yg 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 p id Held at�.� psid Opened at Opened at Held at
nitial Test Closed Tight� Closed Tight '� psid psid psid
Leakedl ' Leakedf' Did not open [ I Did not open f ' Leakedl '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight-7 Closed Tight[ ' psid psid psid
Test gauge used: Make/Model (N��(�+�5 T(a� SN: Q�/���g�
Date Tested for Accuracy: - 3G- �5
Remarks: Tl'1!� !f ( l�lP/� / q,l� �V�C+�,
The above is certified to be true at the time of testing.
Firm Name /4��i(� G�'l�' ,j�i wl Firm A ddress_7�0� ��a✓� -Jy`. ��"(� � ��2 Z �
Certified Tester(print�l �C�lN.�°� F.�S'��q�✓ Certified Tester(signat e)
Firm Phone#'Ll�� �✓' �� ���� Cert.Tester No.��Q��G��J� Date �� ' �7
�
* 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