2016_1008 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: �(?-�'_, r1'lc-�-d-i �L'�
LOCATION OF SERVICE: �y-��f����p�_
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
duced Pressure Principle C�Reduced Pressure Principle-Detector
� Double Check Valve ❑Double Check-Detector
�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �I ���I P'1� Model Number 3S0 Size
�
Located At Ctl�� b �. �� Serial Number � �J"
Is the assembly install in accordance with manufacturer recommendations and/or 1oca1 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 �'�psi Held at �� �psid pened at Opened at Held at
I itial Test Closed Tight� Closed Tight � psid psid psid
�� Leaked� I Leaked�l Did not open � 1 Did not open I I Leaked'�� 1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl l ClosedTight � 1 psid psid psid
Test gauge used: Make/Model/�(�o��o �D a0 D T I�s� SN: ��j(6 O(p(�,�
Date Tested for Accuracy: � (o—��U
Remarks:
The above is certified to be true at the time of tesring.
i , �� / ` �
Firm Name ��I �?�/C�(-' �lGfG�/0 h Firm A ddress ���" /!1 � �/�� J iJ v i`rJ�i S
Certified Tester(pr�nt " G�n� Certified Tester(signature) �
Firm Phone# ��a' ������� 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