2016_0715 IRRIGATION_;y� 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 I.D. # 0570040
(Customer) 7
MAILING ADDRESS: �4_f/ k��a�Gl� ��
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � � �7"/ 1A 90�
,
The backflow prevention assembly detailed below has been tested an maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
-]Reduced Pressure Principle '�Reduced Pressure Principle-Detector
�uble Check Valve -�Double Check-Detector
I�'PressureVacuumBreaker �JSpill-Resistant Pressure Vacuum Breaker
.�
Manufacturer �i(�i���l��j Model Number � �� T Size �
�
Located At_�-Yp�C�- y� � Serial Number �� � �✓�� � � �
�
Is the assembly installed in accordance with manufacturer recommendations andlor local codes? c' �
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 0��psid Held at �r� psid Opened at Opened at Held at
Initial Test Closed Tight���� Closed Tight..� psid psid psid
Leaked. 1 Leakedl �� Did not open 1 Did not open � I Leaked'�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'� Closed Tight I psid psid psid
r
Test gauge used: Make/Model (�i � � �-' S SN: d s� j/� S�
Date Tested for Accuracy: ��J� � �,�
Remarks:
The above is certified to be true at the time of testing.
�� � '
Firm Name �-� � C� Y S i �� Firm Address �]�fl ��X a� ���7�S S .. 1/'�!
Certified Tester(prs nt)�[�-v��p S r(1 i�Certified Tester(si gnature) �
Firm Phone# �/.:�g- � � � Qi��`t� Cert.Tester No.�'}��Q�3�`�0 Date �- � S -- / �
* 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