2016_0819 �w. . _ _ _ _ i
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IRRIGATION (� DOMESTIC FIRELINE 7
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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: .�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT :�
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 ' �
(Customer) �
MAILING ADDRESS: �2�� j�n•��,�� T % �
CONTACT PERSON/PHONE —� "'!�- � -- �
LOCATION OF SERVICE :�'� �i�Ia�,c.� G I'� ('or��:�/t i-%``� ;��U I cf ��
The backflow prevention assembly detailed below has been tested anc��maintained as required by �i
commission regulations and is certified to be operating within acceptable parameters. 4
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TYPE OF ASSEMBLY �
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
,/�'bouble Check Valve ❑Double Check-Detector i
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker °'�
Manufacturer�t-�ti �!��,�; ti�a Model Number 1.�.=� ��r ti 5 � Size � G ���
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Located At -"�,c,�-�T�,� �L�rl�r'�� Y�� Serial Number_�-r�T7 ��y � �
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Is the assembly installed in accordance with manufacturer recommendations and/or local codes? `� ;
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Reduced Pressure Princi le Assembl Pressure Vacuum Breaker �
Double Check Valve Assembly ?�
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check ;.�
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Held at�f�psid Held at ��`� psid Opened at Opened at Held at �
Initial Test Closed Tigh�' Closed Tight�' psid psid psid +'
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t� ';u !x, Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑ �
� Repairs/ � � �
Materials
Used I
,
� Held at psid Held at psid ��`�
Test After Opened at Opened at Held at �
Repair Closed Tight❑ Closed Tight❑ psid psid psid .�
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Test gauge used:Make/Model �;f;0�t�G I k S (,{ SN: �J �a70�� 2 b ;
Date Tested for Accuracy: ���j��„T�/,� j
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Remarks:
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The above is certified to be true at the time of testing. �
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Firm Name "�� p-�✓ � Firm A ddress ��(� ���``��G�`7 � � �
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Certified Tester(print)1,�� ��� ��+����C,*--Certified Tester(signature) ���'�'s��� � � �1
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Firm Phone# `,'��2� �/f1?`o` ����� Cert.TesterNo.�����6d 1���o � Date`��� `,�`�_ �
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* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS �
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS ;
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White-City Copy Yellow-Customer Copy Pink-Tester's Copy "
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