2016_0314 IRRIGATION �1 DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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 OF SERVICE: �)0 (,�,����,p c,/L
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 I �Reduced Pressure Principle-Detectar
�uble Check Valve I i Double Check-Detector
1PressurcVacuumBreaker �Spi11-Resistant Pressure Vacuum Breaker
Manufacturer l.cJ f��/�S Model Number ��b Size 3_�_
� d
Located At ��ti / �/�¢rL,D Serial Number lT.�,5 �/ �� oZ
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � � �S
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 ats��psid Opened at Opened at Held at
Initial Test Closed Tight�.�1 Closed Tight '�� psid psid psid
Leakedl �� Leaked�.. I Did not open I�' Did not open ��� Leaked'��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight f��� Closed Tight J psid psid psid
Test gauge used: Make/Model LD� Gb �/d-�� .��li SN��J�/ �� g �
Date Tested for Accuracy: l� � ��
Remarks:
The above is certified to be true at the time of testing.
FirmName.s� � Q Firm Address�Gv7.���95��[.r� 5���� �i�
Certified Tester(pr:nt)�'jyc/f�1L`-'� �v/L�L` Certified Tester(signatur � � G�
Firm Phone#��o� �'l�'�:�73LJ Cert.Tester No. �S�!� Date .3 �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