2016_0525 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: ' � li, -
CONTACT PERSON/PHONE: � - � L �- :' �
LOCATION OFSERVICE: ��iS('_��''Xl,�d4 ,�� �
—���-�T
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
�Reduced Pressure Principle -1Reduced Pressure Principle-Detector
,�ouble Check Valve � I Double Check-Detector
1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �� ��r��. � Model Number 3s � Size � / �
Located At /I�r�s ��a r►, jh-.e�t; Serial Number ��� �° � I �
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 lnlet Check Valve
1 st Check 2nd Check
Held at 5�b psid Held at Z�� psid Opened at Opened at Held at
Initial Test Closed Tigl� Closed Tight� psid psid psid
Leaked'��. 1 Leaked'���I Did not open f 1 Did not open l Leaked �l
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I i Closed Tight i 1 psid psid psid
Test gauge used: Make/Model /T.�,f1 f/(1���'���iGl SN: (}�r��,���
��--_-r-r�� �
Date Tested for Accuracy: /�- �U'0�
Remarks:
The above is certified to be true at the time of testing.
Firm Name t(�j �}CG(�j��}L��j�"���,�' Firm Address �J�g� " 1��� �:�f�..�1�1��d�� 7S6�j��
�P �)�/—����1��1����� � g )
Certified Tester r^�nt Cert�fied Tester si nature
Firm Phone#=I ����g�?)��_Cert.Tester No.'��(��S���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