2016_0329 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:
$ACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
,. .
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS: ��� � �p f'?�}6 �.4Pp�I1 , ��"O I
CONTACT PERSON/PHONE: r'e Z� 215°I40o
LOCATiON OF SERVICE: � 8 � q m mon �.
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
7Reduced Pressure Principle ' iReduced Pressure Principle-Detectar
ad�oubleCheckValve C�'Double Check-Detector
:1PressureVacuumBreaker f Spill-Resistant Pressure Vacuum Breaker
Manufacturer UV� l ���-5 Model Number �J�� Size ���
Located At �� �E ����" d� P''d�''+'1 b�`�Se al Number � ��1 �o��D
Is the assembly installed in accardance with manufacturer recommendations andlor 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 at � � � psid Held at�"� psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked�] Leakedl '� Did not open '�� I Did not open f'� Leaked l�I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight LJ ClosedTight��-1 psid psid psid
Test gauge used: Make/Model �!I��� � 0��—��( SN: Q���� /Z�
Date Tested for Accuracy: "/—��� ��
Remarks: �'R- ' ��' '�-7 5 �-
The above is certified to be true at the time of testing.
Firm Name �✓U.�0►'� Firm Address `'1�� S ,�p1',�G✓ �+� �����a'�
Certified Tester(pr4nt) �U���(ns � ����e Certified Tester(signature)
Firm Phone# ��� ����� � Cert.Tester No. ���Z��3 Date 3�Z�"� �
* 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