2016_0914 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 I.D. #0570040
(Customer)
MAILING ADDRESS: �I � �t ���
CONTACT PERSON/PHONE: fiYY1 — Q-�,,,��,1/� )r
LOCATION OF SERVICE: �t ( � �� 1Y1 [��.,� ���1
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
�Reduced Pressure Principle ���Reduced Pressure Principle-Detectar
� I�e Check Valve I 'Double Check-Detector
-1PressureVacuumBreaker �Spill-ResistantPressure Vacuum Breaker
Manufacturer �—"J�-C� Model Number �� •J " Size__���`'j
—�
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�d psid Ope at ene at
Initial Test Closed Tight'�1 osed Tight I 1 p � 1 i psi
Leakedl I Leaked�1 D open �1 �d not o en '�1 Leaked� ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'�.7 Closed Tight I�' psid psid psid
Test gauge used: Make/Model ��jQ,i-z�!/��J 5��Z�� SN:�L,�)�L �
Date Tested for Accuracy: �—? �2-7� �'�
Remarks:
The above is certified to be true at the time of testing.
FirmName � Firm Address�'/� �/(,�i�
�_ r
Certified Tester(print) ; � o Certified Tester(signature)
Firm Phone# ���7' /�GC� Cert.Tester No. � � 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