2016_0505 ja .
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
f '
NAME OF PWS: CITY OF COPPELL PWS I.D # (�70040
(Customer)
MAILING ADDRESS: _
CONTACT PERSON/PHONE: � ` �� � y�-
LOCATION OF SERVICE: C— �
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acce�able parameters.
TYPE OF ASSEMB�.Y
I:-!Reduced Pressure Principle �1�educed Pressure Principle-Detector
�Jouble Check Valve �1 Double Check-Detector
�PressureVacuumBreaker CSpill-ResistantPressure VacuumBreaker �
1�
Manufacturer � t 1 t�� r�5 Model Number 3 J�J Size�_
�,, Serial Number �../��� c�v��
Located At ""'
Is the assembly installed in accorc�ance 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
����-, �i Held at Z�� p 'd Held at �•�� p�sfi�' Opened at Opened at Held at
Imtiai�est Closed T�ght� Closed Tight �X psid psid psid
Leaked�.1 LeakedC I Did not open [7 Did not open I I Leaked���� I
Repairs/ �
Materials
Used
� Held at psid Held at psid
Test After Opened at Opened at Held at �
Repair ClosedTight�� ClosedTight'J psid psid psid
/��
Test gauge used: Make/Model !�.: t� � .�J L�G� SN: --�����'�v � ��
Date Tested for Accuracy: � ro `J��a
Remarks:
� The above is certified to be true at the time of tesring.
_� � ` / �� , ;
FirmName L> � ��' ��� � < Firm Address ..�� r�/�LL? '�'��' S y�'��
���- �"�..� _--___
Certified Tester(print) �!� �a l'>t Certified Tester(signature) -•
Firm Phone# �1��"��-� -����� Cert.Tester N��"1�L��5�� 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