2016_0315 IKRIGATION 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 I.D. #0570040
(Customer) //
MAILING ADDRESS: I 3O� �I'Ur1 I e�'�' l�i►r' CO ��� �-J� �(SO I�
CONTACT PERSON/PHONE:LEt,J C S iQS Z '-F- U
LOCATION OF SERVICE: p� e
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
1 R uced Pressure Principle �:Reduced Pressure Principle-Detector
ouble Check Valve CI Double Check-Detector
�PressureVacuumBreaker �Spill-ResistantPressure Vacuum Breaker
G� � �►
Manufacturer� � Model Number u� � Size z
Located At F(�pl'1� O� ����� Serial Number� � ����
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �PS �
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
Initial Test Closed Tightl� Closed Tight �4 psid psid psid
Leaked'�� I Leaked'. 1 Did not open I �I Did not open '� � Leakedl '
Repairs/ u�W D�
Materials
Used
Held at psid Held at psid �
Test After Opened at Opened at Held at
Repair Closed Tight[�'� Closed Tight I�'� psid psid psid
Test gauge used: Make/Model �or►'�hr0. �O � Z�d�� SN: Z5�3GC�
Date Tested for Accuracy: -1 ��
Remarks:
The above is certified to be true at the time of testing.
� �
Firm Name Co�e�� �5D Firm Address 343 l•�ra � ��C
Certified Tester(pr�nt) V1� ��� Certified Tester(signature) �
Firm Phone# �� �q'�o' Q��� Cert.Tester No.!Jt' v�.l.1W��� Date �5 ��
* 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