2016 ��:�
,
IRRIGATION X DOMESTIC FIRELINE r "
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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:
e�, � , � �
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer) �
MAILING ADDRESS:
CONTACT PERSON/PHONE: ` � � �
LOCATION OF SERVICE: 7 �?/�r��r��ra f,?/ �
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 ❑Reduced Pressure Principle-Detector
�Double Check Valve � �Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
�,/ � .,, / /✓
Manufacturer vd'/ ���/ r�� Model Number ��'� Size
Located At �Y� �"/�'�� Serial Number ��7�7 ��'
Is the assembly 'mstalled in accordance with manufacturer recommendations ancUor 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
��f��� � Held atZ� `� psid Held atL"�psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight i psid psid psid
� Leaked'�.] Leaked L J Did not open C Did not open I 1 Leakedl�I
Repairs/
Materials
Used
� Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I�I Closed Tight I 1 psid psid psid
Test gauge used:Make/Model����v ��aGUT�J�U SN: ��1���� �
Date Tested for Accuracy: -��� ���F-'
Remarks:
The above is certified to be true at the time of testing. �
/ -_-''� ,� �y� �j�
Firm Name�G'�ff.���,� �—�`��I��'/��Firm Address-�uT ��/�-�'���'�'r7�:S �
, ���
Certified Tester(prnt�'��'a'`�`'�"��Certified Tester(signature� �__.._----���"
Firm Phone#���' 7� ��� � Cert.Tester No��������� ate
* 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