2016_0413 IRRIGATION � DOMESTIC FIRELINE
The following farm 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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � �� L,�. � G
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
I Reduced Pressure Principle I Reduced Pressure Principle-Detector
�ouble Check Valve �i �Double Check-Detector
_�PressureVacuumBreaker � 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �/i� �'/ry 5 Model Number 3 SU Size�
Located At �/1vrvl__ �,f�-il,� Serial Number j�'j S�S� 7� 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 Cbeck 2nd Check
Held ato�, 5 psid Held at���psid Opened at Opened at Held at
Initial Test Closed Tight�' I Closed Tight ��1 psid psid psid
Leakedf � Leaked. 1 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 G��/5,�9 e o `��i-�� Th v SN:��Uti !(�a7 7
Date Tested for Accuracy: �9� �j�i �^
Remarks:
The above is certified to be true at the time of testing.
FirmName �3 ��� Firm Address��Ga�z �S�s�T�L�-e� Sr�C�s�" T�
Certified Tester(pri nt)/�IiC������.��errified Tester(signature��� ��-� �G�
Firm Phone# � �a�- ��l/— �)�� Cert.Tester No.��g () Date / /
* 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