2016_0831 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�F PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE• L161 Go vw�6v5 _
The baekflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is eertified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
":R uced Pressure Principle `1Reduced Pressure Principle-Detector
oubleCheckValve s�Double Check-Detector
; iPressureVacut�mBreaker :1Spill-Resistant Pressure Vacuum Breaker
Manufacturer iKs Model Number 35O Size � "
Located At t�-'�' �� Serial Number /►'�����i
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �L '
Reduced Pressure Princi le Assembl Pressure Vacwm 8reaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at 3+� p ' Held at� sid Opened at Opened at Held at
Initial Test Closed T' � Closed T' t �' psid psid ' psid
� �� Leaked'�' " , �� ��Leaked�, Did not open =] Did not open : � � Laaked �'�
Repairs! {�L�('r`�`�,1 I�•+�� '
Materials
Used �a.�1l� l�c-�,
� Held at�psid eld at �� ps�
Test After Opened at Opened at Held at
Repair Closed Tight` : Closed Tight Psid psid psid
Test gauge used: Make/Model �eflo sN: :tzr3z5.�
Date Tested for Accuracy: �'jZ�l?
Remarks:
The above is certified to be true at the time of testing.
FirmName �. Firm Address �' X ��� ` 7�
Certified Tester(print) � Certi�ed Tester(signature)
Firm Phone# /������ Cert.Tester Na �'U.U�`�Z Date —3�"�G
*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