2016_0927 IRRIGATION Y 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: ! — �-~ 'i7�Cp��
LOCATION OF SERVICE: `�
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
C duced Pressure Principle ❑Reduced Pressure Principle-Detectar
C�� ouble Check Valve I I Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
� 3��,'
Manufacturer C=�C� Model Number p�� Size
Located At f �VflY1"'�' ��}1�p� C,1jr e r � 'Serial`�`umber ���7c�, ��
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 at�.�ps' � Held at�psifk Opened at Opened at Held at
Initial Test Closed Tight Closed Tight �l� psid psid psid
Leaked����� Leakedl�1 Did not open I ' Did not open I�I Leaked. I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight���� ClosedTight❑ psid psid psid
Test gauge used: Make/Model V�1��1 Y� / 1 �� SN: Q� �� ��Q��
Date Tested for Accuracy: � "'��-1(Q
Remarks:
The above is certified to be true at the time of testing.
Firm Name�,�j ���! �Z.,�jCFirm Address����� �t�1�3v j I�r�x��,_'�
Certified Tester(print) � � ertified Tester(signature) �
Firm Phone# c��'� �'�D��$,� Cert.Tester Na�PC�003�7�Date q��7��(D
* 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