2016_0504 IRRIGATION l,f m `` DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the p�lblic�water su�pl'ier f�or recordkeeping purposes:
S
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer) �
MAILING ADDRESS:
CONTACT PERSON/PHONE: = c ` ,�� ci7,�- 7�- ,���
LOCATION OF SERVICE: )t�� �,"„�i,�, 71�J �,�y�,��
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-Detectar
3�6uble Check Valve �l Double Check-Detector
❑PressureVacuumBreaker ��1Spill-Resistant Pressure Vacuum Breaker
Manufacturer 1'��i� Model Number ,fi��U Size � ��
Located At �1-, �/��fa,i Serial Number �
�-
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? i�/"
Reduced Pressure Princi le Assembl E-'� ! ,1� Pressufe Vacuum Breaker
Double Check Valve Assembly
_ Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�� �� Held at�psid Held at�psid Opened at Ope�ed�at Held at
Initial Test Closed Tightl� Closed Tight psid psid psid
�r I.f�6 Leakedl-! Leakedn Did not open '7 Did not open f 1 Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Neld at
Repair Closed Tight�l Closed Tight C� psid psid psid
` _ ,, ,.�,
-,
Test gauge used: Make/Model���v.� �6!��l-� /����SN: �J,�UlJ�� �'�
Date Tested for Accuracy: � %��/�
Remarks:
�
The above is certified to be true at the tiine���f testing: ��� � �
/ � ��
Firm Name C� G;'p;;�.� /r,-„-� � Firm Address J U�/ L�,. ' ,�
/ . (Q�y-=y H r/� .
V �
Certified Tester(print) ��� �-�rtified Tester(signature)���� �����f'�
,r.�.
Firm Phone# ��- ��--' �`!�;!'/ Cert.Tester No. ICf U/i,v � Date ..i-�-- —f�
* 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
_ _ _ ._�