2016_0628 :
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)
MAILING ADDRESS:
CONTACT PERSONIPHONE: � 3",�,� ���i;, - � ,_,�.�_� ,.-;�.
LOCATION OF SERVICE: J�,� � !�� r_„�a���: �,_t �� � J �
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
i 1Reduced Pressure Principle ` IReduced Pressure Principle-Detector
-�1�1'Double Check Valve !Double Check-Detector
` IPressureVacuumBreaker i iSpill-Resistant Pressure Vacuum Breaker
' � E�:
Manufacturer s .,'� � �-'� P � �,� Model Number `i'�+� Size �
� Located At � � �����4� �-���,� '� ���'J ��-- �
�- / � Serial Number r�• _.� �� �
Is the assembly i�nstalled in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Bre ker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at_.'-� v—,p�' Held at f_-°�psi Opened at Opened at Held at
I�itial Test Closed Tight4'I Closed Tight I� psid psid psid
��;,� ',�;��f Leakedl�I Leakedl I Did not open ! I Did not open i I Leaked'�� '�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i I Closed Tight! I psid psid psid
Test gauge used: Make/Model��r;t'��'� : r��;,��'�? �,�_,.� �� SN: �t����,(.7/�'fr�'�`�
Date Tested for Accuracy: �, _ � -- �,��,
Remarks:
The above is certified to be true at the time of testing.
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Firm Name ,✓�r.'/ �'� .�'�`�'�. >,�'�rm Address � �� � i:,rs�s i �,� ,.
�f� ,�r f
Certified Tester(pr�nt ������r' � �� A,-�t�"''� Certified Tester(signature)��"'.� � ��-�'�
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Firm Phone#�����j���../��„�_�Cert.Tester Nol f � } �� �y Date �%'� , `
� �`r"a �,�.
*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