2016_0506 IRRIGATION X 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 PERSON/PHONE: 0°� (��� ���
LOCATION OF SERVICE• 7 jD ,G/�/yjrr�4� /✓�
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
�1Reduced Pressure Principle I 'Reduced Pressure Principle-Detector
�uble Check Valve ���Double Check-Detector
'�PressureVacuumBreaker f�Spill-Resistant Pressure Vacuum Breaker
�� ��� ���
Manufacturer ` � / �'IS Model Number ��� Size
Located At ���_'_'/�/Z� Serial Number ��7���
Is the assembly installed in accardance with manufacturer recommendations and/or local codes? �,�5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�/,j�,� Held atz- � psid Neld at�•�psid Opened at Opened at Held at
I�tial Test Closed Tightf�-l� Closed Tight C psid psid psid
Leaked� I Leaked❑ Did not open I I Did not open C] Leaked�1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight�:l ClosedTight❑ psid psid psid
Test gauge used: Make/Model L{�lo ��,��OTI�.�� SN: ��ld��D� �
Date Tested for Accuracy: �lp "/(o
Remarks:
The above is certified to be true at the time of testing.
FirmName .LG�,�r /���%4l�7d7Firm Address J'��__J�'�,���t�JEJ/�ii14S O�
Certified Tester(pr�e nt�L'c i Q oit�� Certified Tester(signatur
Firm Phone#�7�—����D a D Cert.Tester No. �Q� 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