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 far 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 /��� ,�-� �/�,F,�'2��
LOCATION OF SERVICE: 7�� .�s�.���,.��
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
�:Reduced Pressure Principle 1Reduced Pressure Principle-Detector
�oubleCheckValve -]Double Check-Detector
�,� ressureVacuumBreaker ��-iSpi11-Resistant Pressure Vacuum Breaker
Manufacturer V � � J N� Model Number l
� J
� �' � Size �
Located At ���"�/ Serial Number
v ..
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�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tighti`� Closed Tight �� psid psid psid
Leakedl J Leakedl I Did not open .i Did not open I Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl : ClosedTight' l psid psid psid
Test gauge used: Make/Model ����L/ �li,�l/� /�.r SN:_���Ul� /�i--
Date Tested for Accuracy: �—o .��L�[d
Remarks:
The above is certified to be true at the time of testing.
Firm Name i ` � Firm Address U LL' � f /✓i"
--�
Certified Tester(print) C� Certified Tester(signaturel�� _
Firm Phone#C/�-����,U�� Cert.Tester No. �l/lJ Date �� � 7 (b
* 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