2016_0506 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: .,�. �Sr ✓�f�
LOCATION OF SERVICE: � �"'�m+� ro r�
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-Detectar
.�oubleCheckValve �7Double Check-Detector
�PressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker
I ' rl
Manufacturer �/i � ��I�?�J Model Number �j�� Size �
.
Located At �y ,`VI�{Y'�✓ Serial Number����? /�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � -�
Reduced Presswe Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
� Relief Valve Air Inlet Check Valve �
1 st Check 2nd Check
Held at ps�d Held at� si Opened�at Opened at Held at
Initial Test Closed Tight Closed Tight psid psid psid
� Leakedn Leaked❑ Did not open ❑ Did not open ❑ Leaked�-1
Repairs/
Materials
Used
Held at psid Held at psid
� Test After Opened at Opened at Held at
Re�air ClosedTight❑ ClosedTight❑ psid psid psid � �
Test gauge used:Make/Model�, ����Ly���KS��SN: �fJf���D (9�
•Date Tested for Accuracy: �,�-C� -�/�p
Remarks:
The above is certified to�be true at the time of testing.
Firm Name�-G�Kpf/�'!� /1''� '6;�Z.Firm Addres��������dl.J��`i�� ���''.
� � �
Certified Tester(pr�nt) ��� ' V�t� ertified Tester(signature}r� �
C_.�'
,
Firm Phone#���•�� Q� C� Cert.Tester No �� �) ate
* 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