2016_0901 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: TC_ I�Y���Y\ � ✓-�
LOCATION OF SERVICE: � D-1 �c�k ��r�V-��
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 �IReduced Pressure Principle-Detector
�Double Check Valve �7 Double Check-Detector
-7PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer , r�
� ��� {7��Model Number �SC.� Size_�
Located At �C� Serial Number �/�/����
Is the assembly installed i 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
� �d Held at 2• ( psi Held at�psid Opened at Opened at Held at
Initi�l Test Closed Tight� Closed Tight �� psid psid psid
LeakedC'� Leaked❑ Did not open '��1 Did not open I 1 Leaked��1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�J Closed Tight��� psid psid psid
Test gauge used: Make/Model � a ��D T�-� SN: Q��dO (�Cv �
Date Tested for Accuracy: J�'�p —��
Remarks:
The above is certified to be true at the rime of testing.
FirmName �C��.S��e �r{� �' Firm Address � l��(�BL� r�� S
Certified Tester(print) �LtY Dl/l`f ertified Tester(signature) �
Firm Phone# ��6�' �,��`�J ��� Cert.Tester Nq����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