2016_0731 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 I.D. #0570040
(Customer) r
MAILING ADDRESS: � �,�j (iLLQ.��[.G� C%1,Q�,f�� 7� �fJw,�j�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: ���
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
�educed Pressure Principle �Reduced Pressure Principle-Detector
� I Double Check Valve ��� �Double Check-Detector
�IPressure Vacuum Breaker I���Spill-Resistant Pressure Vacuum Breaker
Manufacturer �(�1� Model Number baq Size J��
Located At l�-//1 Lf/C�,Q��/Q,�C�'s�f'Iil CC..�a/�-� Serial Number ��3� �
Is the assembly installed in accardance with manufacturer recommendations and/or local codes?
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�psid Held at�psid Opened at �-� Opened at Held at
Initial Test Closed Tight� Closed Tight I� psid psid psid
Leakedl I Leaked'�j Did not open � 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 Closed Tight� I Closed Tight'� J psid psid psid
Test gauge used: Make/Model ��{}�j��QqE SN:���3�,1�'
Date Tested for Accuracy: t�-3-�$
Remarks:
The above is certified to be true at the time of testing.
g-t�^°J �`
Firm Name����re,�r�GGrw�ShG ,� Firm Address pb. �.X�t �QJ�-1$' ���������
Certified Tester(pr°�n �C��ified Tester(signatur ,� � eic�
Firm Phone# �(—I �,,��j'77 Cert. Tester No.���1��� Date '�-��-`� n
*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