2016_0512 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 LD. # 0570040
(Customer) �
MAILING ADDRESS:�.1,c�eol ��o� I.�,.rS.✓ �o S8� N� tis��-�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �O�' {-�o.tis�-v�
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
Re�d ed Pressure Principle 1Reduced Pressure Principle-Detector
�ubleCheckValve -1Double Check-Detector
:-1PressureVacuumBreaker iSpi11-Resistant Pressure Vacuum Breaker
Manufacturer }�{ li e Q Model Number �i � Size�_
1 sca��h��r b����
Located Atb,�ttt ?� �4.�-• Serial Number M � � �/LZ1
Is the assembly installed in accordance with manufacturer recommendations andlor local codes? 1!-�t
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly �
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a3•Z psi Held atZ•7 psi Opened at Opened at Held at
lnitial Test Closed Tight� � Closed Tight I psid psid psid
Leaked 1 Leaked'�I 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 C� Closed Tight[1 psid psid psid
Test gauge used: Make/Model 11��t��J �-�"l� SN: �� �� ��O
Date Tested for Accuracy: G � I ��� _
Remarks:
The above is certified to be true at the time of testing.
Firm Name y-�',��'�� ���``�f�' Firm Address ���x.3����"� �����1����-f�����°
CertifiedTester r�nt �����'RY��(I�G«.�V CertifiedTester si nature � ��p���
�P ) � g )
Firm Phone# ���'- �� �-�1�� Cert.Tester No.�o15� Date ��1 Z'� L
* 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