2016_0524 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 OF SERVICE: ��`j (�,,� ���
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
' iR�duced Pressure Principle 1Reduced Pressure Principle-Detector
��ouble Check Valve '�� �Double Check-Detector
I Pressure Vacuum Breaker I Spill-Resistant Pressure Vacuum Breaker
Manufacturer �i L � (ri'S Model Number �5� Size���
Located At r/�vl�+d���lL� Serial Number ,5 S S �7�
Is the assembly installed in accordance with manufacturer recommendarions and/ar 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
i
Held at�psid Held a��psid Opened at Opened at Held at
Initial Test Closed Tight� I Closed Tig t I psid psid psid
Leakedl I Leaked� I Did not open I Did not open I I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl I ClosedTight �I psid psid psid
Test gauge used: Make/Model Co�t/S U— Ol�%��tJ SN:���Cf /�p�' �
Date Tested for Accuracy: � / �
Remarks:
The above is certified to be true at the rime of testing.
Firm Name �g,g �. � Firm Address(�(�a2/Z L�'�SJIl�L��r/ ��i� �`�
Certified Tester r,nt (C � �� /�
(p � ) m �!�-. ��l7�ertified Tester(signatur�)�����C�,f' �C�,��Lp
Firm Phone#G 7/����U�—}�73�Cert.Tester No. ����_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