2016_0927 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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � Gvl•t�0 g p/'�
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
f Reduced Pressure Principle �:Reduced Pressure Principle-Detectar
i �Double Check Valve C Double Check-Detector
�ressureVacuumBreaker I ��Spill-ResistantPressure Vacuum Breaker
Manufacturer�1��7�w� Model Number �Sv Size�
�
Located At ���� �/a/�-r� Serial Number
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a�� �psid Held at�' �psid Opened at Opened at Held at
Initial Test Closed Tight�l� Closed Tight � psid psid psid
Leaked 1 Leaked�'� Did not open �_; Did not open ! Leakedl �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I_� Closed Tight���I psid psid psid
Test gauge used: Make/Model��H'1�/�'�U '�`aw � rl U SN:d(O�/� <</ � �
Date Tested for Accuracy: �l�2�i�1 �j
Remarks:
The above is certified to be true at the time of testing.
Firm Name�/� .�-�� Firm A ddress ��i.Z.� ���J 6/'�C��-✓ �/���sL` ��—
Certified Tester(prir��l�`'�-� ��'�Certified Tester(signaturey�-_�2�� ���[
y �� ���- 3 >�y
Firm Phone# l� Cert.Tester No.��'aL�--Date ��.Z 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