2016_0507 IRRIGATION� DOMESTIC FIRELINE
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'�I�he �ollowing form must be completed far each assembly tested. A signed and dated original
r�ust be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
� NAME OF PWS: CITY OF COPPELL PWS 1.D. #0570040,�;�
(Customer) �
MAILING ADDRESS:
CONTACT PERSON/PHONE: �,r�',� �-�� .:� , �„�< ����, -a�..;z.� ���rJ
� LOCATION OF SERVIC�: ,��,��; ��', ,��,,;,e,�-;/ � �
�
The backflow prevention assembly detailed bel�been tested and maintained as requi�ed by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
I7Reduced Pressure Principle f 1Reduced Pressure Principle-Detector
It.l�ouble Check Valve I 1 Double Check-Detector
'`-lPressureVacuumBreaker I 1Spill-Resistant Pressure Vacuum Breaker
Manufacturer �'=';�°��.,� Model Number .��'-� Size ���
Located At �— �` � '� �7����f ��/ �''
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�1 ���7�''�9%`.�' S�eria4 Number � r�- ,, � ,
Is the assembly installed in accordance with manufacturer recornrn'endations and/or local codes? �`G_�'
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 .�j psid Held at ,�psid Opened at Opened at Held at
Initial Test Closed Tightl� Closed Tig t I �-- sid psid psid
Leakedl I Leakedl I Did not open I I Did not open i �I Leaked' '
Repairs/
Materials
Used
` Held at - psid Held at psid
Test After - , Opened at Opened at Held at
Repair Closed�Tight l l Close{�Tig�►Y�;1-,.-' psid psid psid
Test gauge used: Make/Model ,�,��1;�; EtG��:'�%.�;����;� SN: �'J.�.��'��0,�`�`°���
Date Tested for Accuracy: ��r{�� ~�,•'� �
Remarks:
The above is certified to be true at the time of testing.
� �' � -�- ,
FirmName �`� l'%i �, f�' %-,;� �t � Firm Address �,���r �--�,: 1'f..� , � .� , .r � �' ��j',
�', ` t,
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Certified Tester rint �: �'`.f'�' � --�
(p )_�� t� ��,���_ Certified Tester(signature) � ..._...
Firm Phone# �i" �,=- �=;:'- C,�:..��; Cert.Tester No. �,�„�r�,�i-�irt�� {� Date_ �i�- �--t��l
*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