2016_0819 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: �Z2. G� � ('J
CONTACT PERSON/PHONE: / — -� (�
LOCATION OF SERVICE: ,�, G� � 7 �
The backflow prevention assembly detailed below has been tested an maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�boubleCheckValve ❑Double Check-Detector
f:�Pressure VacuumBreaker 17 Spill-Resistant Pressure Vacuum Breaker
Manufacturer�lJ(�J ����n�Model Number L✓t��(�5 Size �J �
Located At ��o�� S6�/l��e� �a� Serial Number �+-��3�y 7
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 Tnlet Check Valve �
1 st Check 2nd Check
Held at�psid Held at ��� psid Opened at Opened at Held at
Init'al est Closed Tig� Closed Tight� psid psid psid
!� iC� (J� Leaked� LeakedC: Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model �pt��l� ���( SN: C) ��7d���
�
Date Tested for Accuracy: �/2�,�/�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �c� �1'�✓ Firm Address 3�C� ���r�`^'`�
Certified Tester(print) ��OC��t����''Certified Tester(signature) ���'���
.
Firm Phone# tC7Z'%�'1��� Cert.Tester No.�QCX3�r YG� Q 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