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: �d c ' 7 "
LOCATION OF SERVICE: 7��_�...,�,�f/
The backflow prevention assembly detailed below has been tested and maintained as required by
coinmission regulations and is certified to be operating within�acceptable parameters.
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TYPE OF A`S�EMBLY
�JReduced Pressure Principle CJReduced Pressure Principle-Detector
�oubleCheckValve ❑Double Check-Detector
I ressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker
�` � �
Manufacturer �/l����Cr„f Model Number J,�U Size �
Located At �C��r/ Serial Number �,Z�/ ���
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 at��l/�psid Held at��psid Opened at Opened at Held at
Initial Test Closed Tighti Closed Tight _ psid psid psid
Leakedl '� Leaked�� Did not open [1 Did not open ! I Leakedf.;
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight''�_1 Closed Tight❑ psid psid psid
Test gauge used: Make/Model li�o,L��// SN: ��/UU�� 5�
Date Tested for Accuracy: � �
Remarks:
The above is certified to be true at the time of testing.
Firm Name � � ' Firm Address !J Lv �� ,
Certified Tester(print) r i ied Tester(signature) lG � ,P
�
Firm Phone#�7����,����� Cert.Tester Na � ��li,rJ � 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