2016_0714 tRRIGATION W�"' DOMESTIC FIRELINE
The foltowing form must be compieted for each asscinbly tested. A si�ed and dateci vriginal
must be submitted to the public water supplier for recordkeeping pu�-�mses:
BACKFL��1'4'PREVENTION ASSEMBL�'TEST A.ND�IAINTENAnCE REPORT
NAME OF PWS: CITY OF COPPELL PW`S 1.D. #057O��U
(Customer) -- -- _— ___-
MAILING ADDRESS: - ,_ . .. , ',:
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CUNTACT PERSON,'PHONE: -�
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LOCATTON OF SERVICE: , ,,� � ,�;�-��., �''cy,k -• �
The backflow pre��ention assembly detailed belcn�•has been tested and maintained as required by
commission regulations and is certified to be operating within aeceptahle parameters.
'TYPE OF ASSEMBLY
Reduced Pressure Principle Reduced Pressure Principle-Detector
DoubleCheckValve Double C'heck-Detector
PressureVacuumBreaker Spill-Resistant Pressure Vacuiun Breaker
Manufacturer �=�� ��Y � '��- � ���� Size �"d','
-------�.---Madel Number___ _.__a-. �a---.---
Located At _ � _.;� :.�� '�..�_' � i��t,.�._.,�-' Serial Number � `-_�% -�' �'�C �� .�
Is the assembly installed in acc�rdance with mamifacturerrecormnendations and/or local codes? ` j .' �
Reduced Pressure Princi le Assembl Pressure Vacuwn Breaker
Double Check Vah-e Assembly
Relief Valve Air Inlet Check Valve
1 st Cheek 2nd Check
Held at��_�l psid Eield at.<�"�psid Upened at_.__.__ Opened at Held at
lnitiaf Test Closed Tight ✓` Closed Tight � psid psid �sid
[.eaked Leaked id not open Uid not open Leakcd
Repairs/
�rlaterials
Used
Held at_.___psid Held at______psid
Test After Opened at Opened at f�eld at
Repair <<osedTight ClosedTight �s��} psid �sid
Test gauge used:Makc/Model fF� °� `�r=�' -�' � SN: -. �-F
Date Tested for Accuracy: f ? - � "�
Remarks:
The above is certified ta be true at the time of testin�.�
FiITIl Na�11e �j '�' �'t`� ;� ,�' � ;i` �' Firnl A ddress - I��'< � _ . , ��..� �s����. �� � ,� , ... .� � . .
Certificd Tester(pr_nt) -__� '�' `�-�_:.��` �"C'ertified Tester(signature) : F'� x"�`"'� �
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Firm Phone# �" I� `� - ' . �
.� "���'� Ce�t.Tester No - � Date �" ������ � ,��
*TEST RFCORDS MUST BE KEPT FOR AT LEAST THREE YEARS
��USF.ONLY MANt1FACTURER'S RFPLACF.MENT PARTS
White-City Copy Yellov►�-Customer Copy Pink-Tester's Capy