2016_0513 (2) 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 MAINTENAIYCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: ..--�
CONTACT PERSON/PHONE: ��'�=-'- �
e' • � f�
LOCATION OF SERVICE: + � � y •�:
The backflow prevention assembly detailed below as been tested and maintained as required by
commission regulations and is certified to be aperating within acceptable parameters.
TYPE OF ASSEMBLY
� 1Reduced Pressure Principle I 1Reduced Pressure Principle-Detector
�Qbouble Check Valve i IDouble Check-Detector
i IPressureVacuumBreaker f ISpi1l-Resistant Pressure Vacuum Breaker
� it
Manufacturer ,-c;'_.�:�?�'_(v Model Number �'��J Size �
� �. ,
Located At �,1;� r"r'� Serial Number ,.t �/
���"� " `
f�=�.�_.
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��� psid. Opened at Opened at Held at
initial Test Closed TightlUr Closed Tight i psid psid psid
Leakedl I Leakedl i Did not open 'I ! Did not open i � Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight i 1 ClosedTight I l psid psid psid
Test gauge used: Make/Model_,^'���}�� ���, �-�� ����1'��� �"+ ��,j SN. �>�..�f(,�� �i,,�i,t�
Date Tested for Accurac �:� ` ���
Y� " �:�5' �
Remarks:
The above is certified to be true at the time of testing.
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Firm Name / ,����,l�'��' ��'"�/,�;�Firm Address_7Cf� ,r/'0 ^ ,
1i J S,o t�r i" , �� ,
,,-, �-/ _
Certified Tester(print) '��;��-�� ��''�,�n� � Certified Tester(signat e) � � �".