2016_0701 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: ,%L ��� ��� �),Z-���,��
LOCATION OF SERVICE: �/Z S �,a,De�/
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
1 Reduced Pressure Principle -I Reduced Pressure Principle-Detectar
�ouble Check Valve ��I Double Check-Detector
1 ressureVacuumBreaker [�Spill-Resistant Pressure Vacuum Breaker
I'
Manufacturer ��/,� �f Model Number �Jv Size �
Located At �_�_ �_� �f� ��� Serial Number�'"/������-,
�� v
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
1 st Check 2nd Check
Held at�psid Held at�✓�psid Opened at Opened at Held at
Initial Test Closed Tight�:�/ Closed Tight �� psid psid psid
Leaked.l Leakedf 1 Did not open ❑ 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�1 Closed Tight L'� psid psid psid
Test gauge used: Make/Model /��//� �7"U��iui�%�v SN: C�%/j/�6 y-
Date Tested for Accuracy: �—���i�/l
Remarks:
The above is certified to be true at the time of testing.
FirmName � � e� Firm Address ,�U �L-,.�/��,,._,� �,eii�,s� �✓i;
Certified Tester(pri nt) �j �� Certified Tester(signature) � -
Firm Phone#57L—�Z2�� Cert.Tester No. v � � Date �� �
* 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