2016_0719 IRRIGATION � DOMESTIC FIRELINE
The followin� form must t�e completed f�r c�acl� assembly tc:sted. A signed and dated original
must be submitted to the Public water supplier for recordkeepin�purposes:
BACKFLUW PIt�'�'ENTION ASSF.MBL�'TEST AND MA11iTENANCE REPORT
NAME OF PWS: CITY OF COPPEL,L PWS 1.D. #0570U40
(Customer) �
MAILI�IG ADDRESS: ��=-��,_ ,.; ; ;:, ;,, _ ;�-� � �. �. � �
CONTAC'T PERSONIPHONE: �
LOCATIOV OF SERVICE: __� �' `� � �� ;�''�� i` :�'";rf� � ___ _
The backflow prevention assembly detailed below has been tested and maintained as required by
cc�mmission regulations and is c�rtified to bz o�rating��ithin acceptable parameters.
'T�'PE OF ASSEMSL4'
Reduced Pressure Principle Reduczd Pressure Arinciple-Detectar
.�I�ouhle Check Valve Double C'heck-Detector
PressureVacuumBreaker Spiil-Resistant Pressure Vacuum Breaker
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_., ..
Manufac.�turer � ��'� �.:�` �' Model Number ,�' '% L...% Sizc �' '
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Located At ,r' ff��k.- �._,�:&,�.,cf c� Serial Numbcr ,s' a„�+ — i t ��'-, t.� �;
Is the assembl_y installed in accordance with inamifacturer recommendatic�ns an�:'or local cod�s`? '--;�.�'�
Reduced Pressure Princi (e Assembl - Pressure Va�uum 8reaker
Dauble Check Valve Assembty
ReliefValve Air lnlet Check Val��e
1 st Check 2nd Check
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Held at�� ,w psid Held at ''p- �_psid O�ened at_.�_ Opened at_ Held at
Initial Test Closed Tigl3r" Closed Tight...»� psid psid Psid
Leaked l.eaked ' id not open Did not open Leaked
Repairs'
Materials
Used
Held at psid Held at psid
Test After Op�ned at Opencd at Held at
Kepair Ctosed Tight Closed Tight ' psid psid psid
Test gauge used:Make,nvlodel � � �� 4.�, ,�' ,��` �;''�i _„ lSN:__ -'} ` �. ;`�; �-�__�
Date Tested for Accuracy: ;`�- .;.�- ;.�
Remarks:
The above is certified to be true at the time of tcsting. T �
,
FirmName�_ #``'� .'~,� '�; � _�� �. .e.. ::' a�'Firm Address �:� �s� L'�� �,:�. .,._ � -, �.
�:,� - � � ;r,� 'rY �~ i.�� ,�,���zL
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(P )'w` ? gnattUe)— _...,,�- �; �
Certified Tester r:nt #� :_ � ,�':� L`l�`�;�fti Certified Tester(si ' ��"" ;
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_ w = :�. �, .ti, 3� -:
Firm Phone# �� �' ' � � ' � `r � Cert.Tester No.°. s. �-°�-�_-': 'ro � 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