2016_0826 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: ` � � r � � 75c�`19
CONTACT PERSON/PHONE: ` � '" ' ��
LOCATION OF SERV ICE:
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
C�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve �Double Check-Detector
'� IPressureVacuumBreaker IlSpill-ResistantPressure Vacuum Breaker
/ l, �(
Manufacturer �Qi(_'�Ci� Model Number ��� Size �
Located At �'���°it� Serial Number� �� �� �
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? �S�
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�C.,�jsid Held a�psid Opened at Opened at Held at
Initial Test Closed Tigh�f Closed Tight� psid psid psid
Leaked�l Leaked� I Did not open [�' Did not open �l Leaked�'�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight f�'� Closed Tight�J psid psid psid
Test gauge used: Make/Model� � �o��(�,�"�J'� SN: ����J�y�
Date Tested for Accuracy: �r'����
Remarks:
The above is certified to be true at the time of testing.
Firm Name ..��� _ � �C�G� �/�,'�,�Firm Address ���Q�;��{� ������D ���7���
Certified Tester rar.t Certified Tester si nature �
�J .
�p � )��I�d�Q� ( �g )
Firm Phone#�7r� �-/���� L�Q Cert.Tester No`�/�(���7� Date CJ �� ��-rG
* 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