2016_0807 IRRIGATION 'V 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:
LOCATION OF SERVICE: ��j� - ,C2.�L�
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
�1 Reduced Pressure Principle I �Reduced Pressure Principle-Detector
�yPfouble Check Valve �]Double Check-Detector
[ 'PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
� �
Manufacturer G�i!�h«.S Model Number �,5 O Size/_
Located At �2CI�y��¢,iLd Serial Number�,�j'r��j��
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
He1d at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight ,� psid psid psid
Leakedl ��� Leaked� I Did not open f � Did not open ' ��� Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at �
Repair ClosedTightl�` ClosedTight��1 psid psid psid
Test gauge used: Make/Model��s1 �p 4�'J-,Zp,v %�-� v SN:��DO� /L 9' 7
Date Tested for Accuracy: ��a 9���i
Remarks:
The above is certified to be true at the time of testing.
�
FirmName $� ��� Firm Address�/���i9���viL�t/ �C/f�SG �Y
Certified Tester(prf nt)l'!'l�Cl�9�L �v��(y Certified Tester(signaturey�%�E��
Firm Phone# 9�p?- ��a— �7 3r�Cert.Tester No. �S �� Date � 7 ��
* 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