2016_0920 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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:
LOCATION OF SERVICE: ��ji � - c�rti 1 /�ti �Opre7
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
���Reduced Pressure Principle i�Reduced Pressure Principle-Detector
�oubleCheckValve I�7Double Check-Detector
�-'PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer /T!/1.�7!iy S Model Number �s'� Size�_
Located At �/�/rY���Q Serial Number ��S��f��
�—
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 a� � psid Held� � psid Opened at Opened at Held at
Initial Test Closed TightJ�4� Closed Tight� psid psid psid
Leakedl�I Leaked I�I Did not open ; 1 Did not open � I Leaked� '�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight-] ClosedTight�_' psid sid
p psid
Test gauge used: Make/Model EO'ti'1�i�!}-<p �yp-aZ�f fj v SN: Ol0�� ��i g �_
Date Tested for Accuracy: �/ L
Remarks:
The above is certified to be true at the time of testing.
Firm Name s,G �Q� Firm Addressl/GiZ� �g.S/IJ/�Y�r/ 5��� ���
Certified Tester(print��G��'Z–bus�iL�Certified Tester(signatur��'j���4� f��s�[
Firm Phone# ���� 9��.��,J LJ Cert.Tester No. O ��� Dat�/�d!/ �i
* 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