2016_0622 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: _b� YV�.LT ✓��
LOCATION OF SERVICE: I� ��1'Y��P_�''f�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 ❑Reduced Pressure Principle-Detector
�ubleCheckValve ❑Double Check-Detector
�PressureVacuumBreaker f 1Spi11-Resistant Pressure Vacuum Breaker
I }� / il
Manufacturer / i � ��I1��j Model Number �,SCJ Size
Located At Q�l �•G��✓ Serial Number�����/�
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� si Opened at Opened at Held at
Initial Test Closed Tight � Closed Tight _� psid psid psid
Leakedl '� Leaked� I Did not open I�1 Did not open _ I Leaked��-1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'�.7 Closed Tight�1 psid psid psid
Test gauge used:Make/Model�`J��{Z�����,�,j��SN: ������� �9�
Date Tested for Accuracy: ��2—/(�
Remarks:
The above is certified to be true at the time of testing.
Firm Nam�G��� /��F Firm Address��.� �,���h���5 �!��
Certified Tester(pr�nt) ���� � Dh-� ertified Tester(signature
Firm Phone#�a��� ��-� Cert.Tester No �� � ate (o �. /�
* 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