2016_0324 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 I.D. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OFSERVICE: J�� C����"j� `L
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� �Reduced Pressure Principle !�I Reduced Pressure Principle-Detector
��(TSouble Check Valve ��� 'Double Check-Detector
'-IPressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer �J!�,�?��v5 Model Number �5 U Size��_
Located At��� �/�¢�l Serial Numbe� ���/loo�
Is the assembly installed in accardance 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 a�► � psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�l- Closed Tight � psid psid psid
Leakedl � Leaked.1 Did not open I Did not open I Leaked� '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opencd at Opened at Held at
Repair Closed Tight i�� Closed Tight' I psid sid
p psid
Test gauge used: Make/Model ���6Q6}C Yv-a� T� v SN:��D�!(��3 7
Date Tested for Accuracy: 9 / l/ S
Remarks:
The above is certified to be true at the time of testing.
Firm Name_�� �r� Firm Address��� �/Fl S�I/�/l�s�+� S�G�SC`i l�
Certified Tester(print�It���� �(,2�j� Certified Tester(signature��'��•G�Q,�/L.—���`��t�p
Firm Phone#�7��1�(]'— � �.�� Cert.Tester No.(�S�U Date .2�'! �/�s
* 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