2016_0708 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: /� � �C Q,t1(][.�L
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
� IReduced Pressure Principle ' �Reduced Pressure Principle-Detector
�ouble Check Valve Double Check-Detector
� IPressureVacuumBreaker � ��Spi11-Resistant Pressure Vacuum Breaker
Manufacturer 4J���/�'�Hi-,S Model Number ,�,��' Size�__
�� �Ssbs3 y
Located At �l�l Serial Number
ls the assembly installed n accordance with manufacturer recommendations andlor local codes? l �
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a�•�psid Held at�- �'psid Opened at Opened at Held at
Initial Test Closed Tight I Closed Tight I � psid psid psid
Leaked� I Leaked I�I Did not open I 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 ClosedTight'�.1 psid psid psid
Test gauge used: Make/ModelCD,r�lf�!!�-�O �-14�tc+� r6ilr SN:OCvC�`'� /li �1'7
Date Tested for Accuracy: � ! �i��
Remarks:
The above is certified to be true at the time of testing.
,,�e� ..� r„ ?
FirmName,�� ��� Firm Address�lia��G�SIJ���S�-�/ �/�L���G /j�
Certified Tester(pr:nt����.����f',�ertified Tester(signature) �!��Cs i�
Firm Phone#��-���.3� Cert Tester No. ���� Date (
* 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