2016_0907 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: �'��•t G`2 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
'��Reduced Pressure Principle C�Reduced Pressure Principle-Detector
�oubleCheckValve '� IDouble Check-Detector
PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer w/�. �'I rh/S Model Number �.S � Size��
r ^
Located At ��/y� �/ 20 Serial Number_/7-,sS� �7`h
is the assembly installed in accardance with manufacturer recommendations and/ar 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�'3 psid Held at�' �psid Opened at Opened at Held at
Initial Test Closed Tightf� Closed Tight '�/ psid psid psid
Leaked 1 Leakedl i Did not open ���1 Did not open � Leakedl �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight'��_7 ClosedTightf��'� psid � psid psid
Test gauge used: Make/Model��h�eo �t0;?�o T/'!v SND6dy�G g�
Date Tested for Accuracy: ��g��
Remarks:
The above is certified to be true at the time of testing.
FirmName �'/3 .�5�2 Firm Addres���'1�3S�viL��v �/¢C S'G
.i
Certified Tester(printyyJ�C��L �u��jLt Certified Tester(signatur ��,�����
7
Firm Phone#'97� ��.��.�Cert.Tester No. O ��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