2016_0831 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: / r � -
CONTACT PERSON/PHONE: `�� �'�
LOCATION OF SERVICE: ��rd�Y� �
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
f�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve C�Double Check-Detector
I PressureVacuumBreaker CSpill-Resistant Pressure Vacuum B��,aker
� /
Manufacturer � t ��T_Model Number ��� Size�_
Located At � 0 Serial Number � ��� ���
Is the assembly installed in ccordan e 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 at � psid Held at�psid Opened at Opened at Held at
InitialTest ClosedTight ClosedTight� psid psid psid
Leaked` 1 Leakedl '� Did not open I Did not open C1 Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I ' Closed Tight� I psid psid psid
Test gauge used: Make/Model�����o�0i;�'��G'�1 SN: d�1����Y
Date Tested for Accuracy: `-�-/7�/
Remarks:
The above is certified to be true at the time of testing.
Firm Name�,(1��l/1'����.����Firm Address q�y I(���,��{rC/�P. /71� 1 //I ��rj��
Certified Tester(pr:nt)��Q� Certified Tester(signature) 1..�"1���<''���.
Firm Phone#�����p��.���� Cert.Tester No: 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