2016_0908 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 far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS: �3�3 y�,. �,� ��� � � � ,
CONTACT PERSON/PHONE: C.� ` C.' --� � U
LOCATION OF SERVICE: �-0 (.Jran e
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
❑R uced Pressure Principle �IReduced Pressure Principle-Detector
C ouble Check Valve C�Double Check-Detector
C:1PressureVacuumBreaker C,'Spill-Resistant Pressure Vacuum Breaker
Manufacturer �rJ G� Model Number ��� Size�
Located At �pi•��. o�'` �� 1'h Serial Number � �� S��
Is the assembly installed in accordance with�manufacturer recommendations and/ar local codes? °tS
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air lnlet Check Valve
1 st Check 2nd Check
Held at Z�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�l Closed Tight [jo psid psid psid
Leakedf 1 Leaked'� l Did not open �7 Did not open I � Leaked'���I
Repairs/
Materials
Used
Held at psid Held at psid
Test After � Opened at Opened at Held at
Repair Closed Tight I�l Closed Tight I psid psid psid
Test gauge used: Make/Model_�M�t�C.O `�U` ��I�- SN: �S�p(�C�
Date Tested far Accuracy: ��/$'�/S
Remarks:
The above is certified to be true at the time of testing.
Firm Name � �D�}'�ll �5D Firm Address f�� `�►"� 1 t°�' �',� � �l '7�-�
Certified Tester(print) U `� Certified Tester(signature) � �
Firm Phone# Z I� '-T /(•''�j��(� Cert.Tester No.�������� Date / � �6
* 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