2016_0731 (2) 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: �3�� C� � �j�p�� ll Ct,L/f1 P.O
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � /y��
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
� iReduced Pressure Principle IReduced Pressure Principle-Detectar
�ouble Check Valve ���� Double Check-Detector
� �PressureVacuumBreaker ' ISpill-Resistant Pressure Vacuum Breaker
Manufacturer T///lG-� Model Number aOOd�5 Size �
Located At��DC"�03�(�il,$�PXI/�Le I�jQrr� Serial Number_ l���p�—
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�l psid psid psid
Leakedi � Leaked I 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 I psid psid psid
Test gauge used: Make/Model`4'�p,��S '�'� qQE SN: ����J��l �
Date Tested for Accuracy: ` �� 3•�5
Remarks:
The above is certified to be true at the time of testing.
� " �e��^g �l�i'I 4
Firm Name� ���} ��p�v�p'.�''�' Firm Address �. �Q�l .�,�
Certified Tester(pr:nt) �C'�°�Cerrified Tester(signature
Firm Phone# 1S/ ��,��g��7,�Cert. Tester No����(p Z Date �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