2016_0705 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 far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) �
MAILING ADDRESS: u'�--�.
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: ✓t �.1L�
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
C�Reduced Pressure Principle I ��Reduced Pressure Principle-Detector
-� ouble Check Valve I �Double Check-Detector
� PressureVacuumBreaker f-Spill-Resistant Pressure Vacuum Breaker
Manufacturer �L��L�1 Model Number �� Size 3�
Located At �/^' `-'J Serial Number �L �� z�i "7
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 Inl t Check Valve
1 st Check 2nd Check
Held at� Z psid Held at J, a psid O ned � O at
Initial Test Closed Tightf✓� Closed Tight � psi sid
Leakedf�I Leaked'�. 1 Did not open '�.1 ' not open I I Lea ed� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C i Closed Tight I�1 psid psid psid
Test gauge used: Make/Model_r��{'�2l�4 � � � SN: ��1-0�
Date Tested for Accuracy: � ���'-� �-
Remarks:
The above is certified to be true at the time of testing.
Firm Name�`� ��?L'"�^'% Firm Address � `V',
Certified Tester(print) r�.�-j Certified Tester(signature)
Firm Phone# Z�� �7�U Cert.Tester No. � Date 7 �� �
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- City Copy Ye11ow-Customer Copy Pink-Tester's Copy