2016_0817 IRRIGATION i� 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: �o�..� �5 p��rr��
CONTACT PERSON/PHONE: ,
LOCATION OF SERVICE: � �'� S
The backflow prevention assembly detailed below has been tested ari aintained as required by
commission regularions and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
i-_-R uced Pressure Principle rReduced Pressure Principle-Detector
ouble Check Valve I ����Double Check-Detector
'��Pressurc Vacuum Breaker ��'�I Spill-Resistant Pressure Vacuum Breaker
Manufacturer�_ �� Model Number � � � Size-����
/ �
Located At � ^�►�g�L�^� Serial Number ��)�9',��
Is the assembly installed in accordance with manufacturer recommendations andlor 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
• c
Held at���� Held at�psid Opened at Opened at Held at
Initial Test Closed Tight Closed Tight� � psid psid psid
Leakedf�1 Leaked��. I Did not open '�;�1 Did not open I 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�-=1 psid psid psid
Test gauge used: Make/Model w/�,�/Lc_� SN:��'�.�����
Date Tested for Accuracy: �� $ �— �,� �
Remarks:
The above is certified to be true at the rime of testing.
n `` „ �G /
FirmName l�Cl'�'/C��, Firm Address�?��C � �s ��T)'/.l'/���'pDC
i v
�y A���'C�
Certified Tester(print)����1' � Certified Tester(signature)
Firm Phone#��� (e.-� ��-���� Cert.Tester N �� �G�� 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