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 I.D. #0570040
(Customer) �
MAILING ADDRESS:
CONTACT PERSON/PHONE: �y 7" �
LOCATION OF SERVICE: 7 �f �h���
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
:iReduced Pressure Principle �Reduced Pressure Principle-Detector
�oubleCheckValve CDouble Check-Detectar
I ressurcVacuumBreaker !-Spill-ResistantPressureVacuumBreaker
Manufacturer �/1/,��i'.,� Model Number��!J Size ���
Located At ���� � Serial Number ��-] �J'���
,�—+ �
Is the assembly installed in accardance with manufacturer recommendations and/or local codes? /-p�
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�psid at�psid Opened at Opened at Held at
Initial Test Closed Tightl� Closed Tight � psid psid psid
Leaked`�1 Leakedl 1 Did not open I I 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-1 ClosedTight Ci psid psid psid
Test gauge used: Make/Modeli���L_�fl✓,tGs�?��b�_SN: �J�`r/lJG��f
Date Tested for Accuracy: � ��L—/�
Remarks:
The above is certified to be true at the time of testing.
FirmName � ` Firm Address,T� /v� �.���,���i;
d"
Certified Tester(print) Certified Tester(signature) �
Firm Phone#�7��Zy�v�J Cert.Tester No. l/lJ Date_��CJ
* 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