2016_0805 r�.
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: o'/ ��Y�� 7'�--� t/�S
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �� � � ' J Ul J �'1,� �
The backflow prevention assembly detailed below has been te ted and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
' iRe uced Pressure Principle -1Reduced Pressure Principle-Detector
� ouble Check Valve ��Double Check-Detector
1PressureVacuumBreaker CSpill-Resistant Pressure Vacuum Breaker
Manufacturer �'�,�~�/� i r�� S Model Number � v'� T Size j � //
�.. �/
Located At "�'� � �' T Serial Number,� ��.3 � �--�
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�—-�psid �-Ield at�psid, Opened at Opened at Held at
Initial Test Closed Tig t 1 Closed Tigh� psid psid psid
Leakedl 1 Leaked�I Did not open 7 Did not open � I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl i ClosedTight .I psid psid psid
Test gauge used: Make/Model__�IY/��' V` � SN: � �ja��7� } �
Date Tested for Accuracy: ��- � p—�� �� �j
Remarks:
The above is certified to be true at the time of testing.
r'1 � � f
Firm Name �'U�i-�� T`� i' Firm Address , � �p �-�$ �j ! I 1 �����c'3�J�
� �
Certified Tester(print) ''` � ' ��ertified Tester(signature ���������-' `�
�. �
Firm Phone# � �" ��� ��/ �Cert.Tester No� ���%� �� Date � 'C�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- Ciry Copy Ye11ow-Customer Copy Pink-Tester's Copy