2016_0713 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) l{� , � � n
MAILING ADDRESS: / `� y i 1/C�1C/�'1 V-��IZ�� �c�N l
CONTACT PERSON/PHONE: v'` ��� �_�J(�� �� Z
LOCATION OF SERVICE: l� A�f1l�
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
' R�e ed Pressure Principle �;Reduced Pressure Principle-Detector
� ��oubleCheckValve �Double Check-Detector
!1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer I"��� Model Number �� -' `" Size�/
Located At � '�-�� Serial Number �� ��� �2—
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 Inlet Check Valve
]st Check 2nd Check
Held at��psid Held at�psid Open atf� Opene Held a
InitialTest ClosedTight�� 1 ClosedTight �1 - psid
Leaked�.�I Leakedl�i Did n t o n �� 1 Did ot pen i , � I
Repairs/
Materials
Used �°
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight��; ClosedTight[�I psid psid psid
Test gauge used:Make/Model �/1�i/,�; �L t)Z-U'*� SN: �'L_�'S��^?�
Date Tested for Accuracy: '���1�`�'
Remarks:
The above is certified to be true at the time of testing.
Firm Name � - ��""�'r'- Firm Address /�'1�.�
� Certified Tester(print) �i(,,...,�e�_Certified Tester(signature)
Firm Phone# 2- � 1� ,��,•�{� Cert.Tester No. �P_��� Date �" � 3���o
* 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