2016_0719 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 LD. # 0570040
(Customer) '�� �#../
MAILING ADDRESS: . /O/��jp''p llit C�' lr�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: '��� � �Y�/!�l Q�S'
The backflow prevention assembly detailed below has been tested and mtained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
'� �Reduced Pressure Principle I �Reduced Pressure Principle-Detector
�ouble Check Valve I '���Double Check-Detectar
'���I Pressurc Vacuum Breaker � I Spill-Resistant Pressure Vacuum Breaker
Manufacturer1���t,e� Model Number 3 �C� Size '� , r
Located At � � Serial Number �
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�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leaked�� I Leaked`�I Did not open I Did not open ' Leaked i
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opcncd at Held at
Repair Closed Tight'�� � Closed Tight���' psid psid psid
/ �� �
Test gauge used: Make/Model (��/�j�• 1.� S SN:_ ���3l���
Date Tested for Accuracy: �: / �'-- ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name `� � LO(�YS/C�/'� Firm Address +�� / QX � -� � � � �^ f�i�j'��
�' __.
Certified Tester(prtnr)��' � L.7'' Certified Tester(signature) a����
Firm Phone# C � ����Cert.Tester N d���i � 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