2016_0805 (2) 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
.
(Customer) � ��
MAILING ADDRESS:
CONTACT PERSON/PHONE: _ d�.. i�Y1C� �/� �
LOCATION OF SERVICE: � G_�j,��vt�)t�►-�
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-Detectar
� �oubleCheckValve ❑Double Check-Detector
'l ressure VacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
1 '' 3
Manufacturer 1 � I 1�1�J' Model Number �� Size
r '
Located At Serial Number , � � �U��'w;
Is the assembly nstalled in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Bre er
Double Check Valve Assembly "
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
���S, � Held at 2-U p id Held at �� U p'sid Opened at Opened at Held at
� Initial Test Closed Tight� Closed Tight 1,� psid psid psic����
Leaked l LeakedC''� Did not open .1 Did not open I Leakedl '
Repairs/
Materials � � � �
Used
Held at psid Held at psid �*'
Test After Opened at Opened at Hel�at
Repair Closed Tight� Closed Tight❑ psid psid psid�'�
Test gauge used: Make/Model DI 7`Q p����u SN: Q 3����P�1' �
Date Tested for Accuracy: �lo`��p
Remarks:
The above is certified to be true at the time of testing.
FirmName � / �/ Firm Address �� vfJ � //l ��/'
Certified Tester(print) � ' '� Certified Tester(signature) � �� `�`����� �
;� � �}
Firm Phone# ���,�v("��ca�'���C� 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