2016_0805 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 LD. #0570040
(Customer) �-�
MAILING ADDRESS: /� .I� �r������=Y' C
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �? I i�l 11.t P
The backflow prevention assembly detailed below has been tes ed and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
] duced Pressure Principle -1Reduced Pressure Principle-Detector
�
� ouble Check Valve -]Double Check-Detector
���PressureVacuumBreaker �Spi11-Resistant Pressure Vacuum Breaker
i
Manufacturer ��'�f� %�` S Model Number � ��� T Size �� ��
� /7 ���-G_,��
Located At �/�� ' Serial Number,
Is the assembly installed in a cordance 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 at��psid Held at�psid _Opened at Opencd at Held at
InitialTest ClosedTight� ClosedTight�l � psid psid psid
Leakedl I Leaked. I Did not open I I Did not open I i Leaked'� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opencd at Held at
Repair Closed Tight�1 Closed Tight�._J psid psid psid
Test gauge used: Make/Model V�/��/�i�v- S' SN: �j�.����(,
Date Tested for Accuracy: �'/' � -� �
Remarks:
The above is certified to be true at the time of testing.
FirmName ����1�5/'�'P Firm Address f��� 1�� �S�S���� ����LT�
'
,__
Certified Tester(pri»t) �(�{/d�3 ��"� Certified Tester(signature) �C'� ��'�'�'�-�-- --y "
Firm Phone# ���������� �?��Cert.Tester N� ����� �� Date `��� 5 —� ��
* 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