2016_0610 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: al-I / II {�' �J � T� � �
CONTACT PERSON/PHONE: � ( /y "�/ - �`7
LOCATION OF SERVICE:
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 �Reduced Pressure Principle-Detector
f�bouble Check Valve 'Double Check-Detector
'��1PressurcVacuumBreaker ! ��Spill-ResistantPressure Vacuum Breaker
Manufacturer I�¢�►tT� Model Number LF Q 7/�Of���Size 3�y �,
Located At �=A��� �j�.��o� �/l'wv Serial Number Q���,�(C�
Is thE assembly installed in accordance with manufac urer recommendations andlar local codes? 5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly �
Relief Valve Air Inlet Check Valve
]st Check 2nd Check
Held at �.� psid Held at �. � psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight � psid psid psid �
Leaked'� 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 Hcld at
Repair Closed Tight'1 Closed Tight I psid psid psid
Test gauge used: Make/Model �ha/�L� SN: (J,jQ�Q��j �
Date Tested for A�curacy: - /o� '
Remarks: � �
The above is certified to be true at the time of testing.
FirmName �`-1��(� Firm Address %4.5 �,� ��s�i� �i�✓k l�i� �a�/e�s TJ�a�.3g
Certified Tester(print) -�� /<�,vvr 50✓i Certified Tester(signature) ,�
Firm Phone#o��y- 3�/��-���_Cert.Tester No. ,(3/��Q� �i� Date �7 �-/Q �- ��?
* 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