2016_0425 IRRIGATION � DQMESTIC FIRELINE
The Following tonn must be campi�t�d fc�r each assembly tested. A signed and dated originai
must be submitted to the public water supplier('or recordkeeping pur�oses:
BACKFLOW PREVENTI�N ASSEMBLY TEST AND MAINTENANCE REPQRT
NAME OF PWS: CITY OF COPPELL PWS I.D. #457004Q
{CusComer)
MA[LING ADDRESS:
CONTACT PERSON/PH�NE: 4
LOCATIfJN OF SER111GE: S
Th�backflow prev�ntion assembly detailed below has been estec!and maintained as required by
con�mission regulations and is certifi�d to be operating within aceeptable parameters.
TYPE OF ASSEMBLY
uced Pressure Principle Reduced Pressure Principle-Detector
oubleCheckValve Double Check-Detectar
'PressurcVacuuinBreaker Spill-Resisiant Pressure Vaeuum Breaker
Manufacturer FG�CO Model Number �,� Size � � '�
Located At �vs.-.� �a�z / Serial Number �`�1t/�IG��. ,�/
Is thc assembly installed in accordance with rnanufacturer recommendations and/or local codes? 7�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check Check
Held at ��� p ' Held ak�psid pened at Opened at Held at
Initial Test Closed Tigh : Closed Tig psid psid psid
Leaked Leaked ' id nat open � '' Did not open Leaked
� � Repairs( �
Matenals
Used
Held at psid F[eld at �sid
Test A�er �pened at Opened at Held at
Repair ClosedTight " ClosedTight : �S�d psid psid
Testgaugeused: Make/Moctel_�l�S�/o SN: /Z/3L56�
Date Tested for Accuracy: L�-(Z `�
Remarks:
The above is certified to be tnte at the time oftesting.
Firm Name �I\/"�'sl� Firm Address �'(J. CC�X �
,� ,
Certified Tester(print) C/J Gertified Tester(�ignature)
Firm Phone# � '«�`� Cert,Tester Na � �te ����
*TEST REGOR�S MUST BE ICEPT FOR AT LEAST THRE�YEARS
**USE ONLY MANU�ACTURER"a REPLAGEMENT PARTS �
White-City Co�y Ycllow-Custamer Cz�py Pink-'T�ster's Copy