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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: K S /� �4 � C:�
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
I ��Reduced Pressure Principle ���iReduced Pressure Principle-Detector
�ouble Check Valve C_Double Check-Detector
� 1PressureVacuumBreaker f 1Spill-Resistant Pressure Vacuum Breaker
Manufacturer�/�L, �'1 r�v�Model Number �S� Size_�'
Located At �i�p'ya�� l//�-� Serial Number_�.�j'�O�"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 Inlet Check Valve
1 st Check 2nd Check
Held a�, rZ psid Held a�0 psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight � psid psid psid
Leaked'� I Leaked'�:1 Did not open I I Did not open f��1 Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I�� ClosedTight' I psid psid psid
.r-•
Test gauge used:Make/ModelG�'�'+,�Ll�Ca �p-�O ! /7�J SN:���t�` ��''` ''7
Date Tested for Accuracy: � L�/ )
Remarks:
The above is certified to be true at the time of testing.
FirmName �� �� Firm Addressl��i`Z���VrrC,�y .�/7`���5`,jj ��
Certified Tester(pr�nt�ie/�9��u'L�[s Certified Tester(signaturel,�.l��E� ��
�..-� v
Firm Phone#��� �' -s'�3GJ Cert.Tester No.����_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