2016_1003 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: J� � � �
CONTACT PERSON/PHONE: �
LOCATION OF SERVICE:
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
❑Reduced Pressure Principle � CiReduced Pressure Principle-Detector
�ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer� �� Model Number �C�y, �_Size�
Located At ' Serial Number 9 g/�a a S
Is the assembly installed in accordance wi 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 Opened at Held at
Initial Test Closed TightC�' Closed Tight CtiY psid psid psid
Leaked❑ Leaked❑ 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 ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model I/�I�� � ��" 9�� SN: S9-�,�,/�
Date Tested for Accuracy: 0.�/O S' �/6�
Remarks:
The above is certified to be true at the time of testing.
FirmName To�}-cJ �' nP ,� � ►i Firm Address 7�09 ,,Grp S'f /�,��,��,5�7
Certified Tester(print)�PSv� �nC�lr,p Certified Tester(signature)
Firm Phone��/5!� 3�J -�1/� Cert.Tester No. �{�OD���7� Date d .3
* 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