2016_0517 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: ��.3,....o �/�— ���f._ ,�'6Z�
LOCATION OFSERVICE: 3����'�k�oo� � CJ����'L�- ,�'v
,r-� .-,.
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. - /
��,�.i T ��-/��- o
TYPE OF ASSEMBLY Z �"�'
' iR�ed �d Pressure Principle I�IReduced Pressure Principle-Detector
.,l�ouble Check Valve -7 Double Check-Detector
; 'PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer ���,�� Model Number � .S"Z� Size 7 �/
�
Located At /L�-h Serial Number �- ,s,$'s006
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 Inlet Check Valve
1 st Check 2nd Check
�� Held at�psid Held at Z-� psid �ened at Opened at Held at
Initial Test Closed Tightl � Closed Tight ' psid psid psid
Leaked' I Leakedl I Did not open I Did not open ' I Leaked '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight L� Closed Tight I psid psid psid
Test gauge used: Make/Model /�LC o �o�o— �S'cJ SN: D,�c 62�,�/�
Date Tested for Accuracy: ����G
Remarks:
The above is certified to be true at the time of testing.
Firm Name�—� �/�=�Cd�v-^ Firm Address ��. f3n� .sf�,3a-7� �,uy�;e,P� T 7J^d�
Certified Tester(print)LyNoit�� Jo^��s Certified Tester(signature)
Firm Phone#���- �s,30��ZZ-�Cert.Tester Nq� �3Z2a Date ���7�/�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy