2016_0926 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: uCt�1 h'1G� � ►�''� ,
LOCATION OF SERVICE: 7��{ �/Y!!'Y�c�>�'ll'� , YJ�� .
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
� 1Reduced Pressure Principle �Reduced Pressure Principle-Detector
rQbouble Check Valve -1 Double Check-Detector
-7PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer ?��I�14�1`J ModelNumber �.�d Size 1_�
Located At�'�Y��F�' Serial Number ����.�a��
Is the assembly installed in accordance with manufacturer recommendations and/ar 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 2•� psid Held at�psi Opened at Opened at Held at
Imhal Test Closed Tightk:.l� Closed Tight psid psid psid
Leaked I�I Leaked�7 Did not open n Did not open G Leakedf,��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C� ClosedTight-7 psid psid psid
Test gauge used:Make/Model�����J �{�o���l�.��.� SN: ��I�JD(p��
Date Tested for Accuracy: �=�"� _ __
Remarks:
The above is certified to be true at the time of testing.
FirmName��`7�,��Y'�(_►�IDI�Firm Address_����J���Lt� �e �'/�1�L� �K •
Certified Tester(pr:nt) .BV' f�L Vl'� Certified Tester(signature) - -��
Firm Phone#��(��� ����Cert.Tester No�l'� Date � �t!
* 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