2016_0901 IRRIGATION '1� 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) f
MAILING ADDRESS: ��� �y'r�f�l.0 ��
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: 'C �,Gl
The backflow prevention assembly detailed below has been tested a maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
ClIj�educed Pressure Principle ��IReduced Pressure Principle-Detector
�'�DoubleCheckValve -]Double Check-Detector
'"iPressurcVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer � �'� Model Number �'�Q fC CT— Size � � �r
Located At N4u d Serial Number�'���--��-s
Is the assembly installed in 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
Held atr�.�+f� psid Held at psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tig psid psid psid
Leaked��1 Leakedf I Did not open I Did not open I Leaked'��� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight� 1 ClosedTight���I psid psid psid
� �� i � 2
Test gauge used: Make/Model f�r�j�/'U- � SN: �� %� � T � �
Date Tested for Accuracy: ��- �—f�—� �
Remarks:
The above is certified to be true at the rime of testing.
n J
FirmName �� ����Y�1�� Firm Address � �' � "_��d � �S fi(� �����
�- ' ����..�-��
Certified Tester(pr;nt) �7� � ��Certified Tester(signatare)
Firm Phone#"%_� ���i�T���Cert. Tester No. C�3� 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