2016_0314 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 MAINTE1vANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: 7�3 c�y � �sv �i�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
'�'Reduced Pressure Principle �IReduced Pressure Principle-Detector
��ouble Check Valve -!Double Check-Detector
C�PressureVacuumBreaker ! Spill-Resistant Pressure Vacuum Breaker
Manufacturer�!�-�'�i'v5 Model Number -35 U Size
-��—
Located At �,v�2o���//¢2.0 Serial Number ��3���.��
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 at � � psid Held at�•� psid Opened at Opened at Held at
Inirial Test Closed Tight� ��� Closed Tight '� I psid psid psid
Leaked� I Leaked��� 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 Closed Tight i '� Closed Tight! I psid psid psid
Test gauge used: Make/Model LO Gb ���� �✓�U SN:� � � �� � �_
Date Tested for Accuracy: � �
Remarks:
The above is certified to be true at the time of testing.
Firm Name �j� �� Firm Address�o�0��•�9S�j/����/ Si¢L'�SL /.�
Certified Tester(print�/�'JICI�/��L$V�(��=Certified Tester(signatur����-��/��Cti?J�
Firm Phone#�7aZ�����73�J Cert.Tester No. �5��'(�_Date.3 ��`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