2016_0927 IRRIGATION�� DOMESTIC FIRELINE
The following farm must be completed for each assembly tested. A signed and dated ariginal
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: —7� �ril�So/t
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-Detector
i�uble Check Valve � !Double Check-Detector
GPressureVacuumBreaker i-Spi11-Resistant Pressure Vacuum Breaker
Manufacturer (,vc�.(�trv S Model Number� S� Size�
Located At �/��v'�!_�//4-2,e7 Serial Number/�.s�s`f �t �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �- L�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
� �
Held� 5 psid Held ata• � psid Opened at Opened at Held at
Inirial Test Closed Tight� Closed Tight ?'� psid psid psid
Leakedl�I Leaked. I Did not open I�I Did not open I � Leaked I I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight. ' Closed Tight f i psid psid psid
Test gauge used: Make/ModelCOrrl�l/J�ad `+tl,eZ� � v SN:d�ay �L � �_
Date Tested for Accuracy: �ae'i 1i (�
Remarks:
The above is certified to be true at the rime of testing.
Firm Name�,L� ,�/� Firm AddressC'oli�2�L�/�-slV��'�' ���5� ��/
Certified Tester(prsnt.��!/�s}�L,Qu/l�,L Certified Tester(signature��� �G�
Firm Phone#�7aZ-�oV 373v/ Cert. Tester No.�s gD Date 9 �/
* 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