2016_0506 , ,
IRRIGATION�_ . DOMESTI� 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:
�
BACKFLrOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
°?i.:� ' � ..
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) �
MAILING ADDRESS: �
CONTACT PERSON/PHONE: ��, CYI�T�n-�`l�C�
LOCATION OF SERVICE: �]C�(������ ��n�4-�t� _ �
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 ced Pressure Principle �Reduced Pressure Principle-Detector
��iP3oubleCheckValve �Double Check-Detectar �
CPressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
��i
Manufacturer �i � ��11"l�J Model Number ��� Size
Located At��}�-{:�r' Serial Number �� ;J (J�.�� '
Is the assembly installed in accordance with manufacturer recommendations and/ar 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�ps' Held at�psi Opened at Opened at Held at�� � � �
nitial Te t Closed Tight� Closed Tight psid psid psid � ��
Leakedl 1 LeakedCl Did not open .�I Did not open L Leaked�
Repairs/
Materials
Used
Held at psid Held at psid � '
Test After Opened at Opened at Held at
Repair Closed Tight 1-1 Closed Tight❑ psid psid psid
Test gauge used:Make/Model �� f7�I U U ��'T K�U SN: ����-'����"
Date Tested for Accuracy: �7 - � ' � �
Remarks:
,�;;
The above is certified to be true at�the time of testing. �
� FirmName . �� � Gt L� irm Address_��`� �/��O/,C��D��//�7S 1���-•
Certified Tester(pr2nt) LiV �/?t1 Certified Tester(signature) ��
Firm Phone#��'�' ,����s�-� > Cert.Tester No. Y��� �'� 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 � � �