2016_0916 IRRIGATION_� DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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)
MAILWG ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: c��`x l/C�C Zt� /1/
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
IReduced Pressure Principle �Reduced Pressure Principle-Detector
�boubleCheckValve IDouble Check-Detector
IPressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
ManufacturerG(�i L.�1 Ir✓5 Model Number �s� Size�
Located At �i��( �//.�-/t.�0 Serial Number�,S��� Lf.3 O
Is the assembly installed in accordance 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
Held a�� � psid Held ato'��psid Opened at Opened at Held at
Initial Test Closed TighQ�— Closed Tight � psid psid psid
Leakedf; Leaked I I Did not open f ' Did not open '�� � Leaked'��� i
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'� , Closed Tight'� I psid psid psid
�
Test gauge used: Make/Model Go���J-e O �aar.v /h� SN:D�oUti /�i 9 7
Date Tested for Accuracy: ����'1�j L
Remarks:
The above is certified to be true at the time of testing.
FirmName � ,C3 ��i�� Firm Addresslilro?U L�/fS,t�i Lu✓ ��'�SG� -T��
Certified Tester(pr�nt��Cfi��L �f�?;L�Certified Tester(signaturey�����L�r�-�
Firm Phone#��o� ���J- ��3`�Cert.Tester No. ���_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