2016_1013 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: /U r� �YO '�G�.c-r S
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: '�j��D O c� v-�
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
C�Reduced Pressure Principle ��IReduced Pressure Principle-Detector
�ouble Check Valve '��Double Check-Detector
I��'�PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer W(°��/�--�ug ModelNumber � s� X�t Size 3 ��
� ,4s�38��
Located At "� 1�'41.�� dY/ Serial Number
Is the assembly installed i accordance with manufacturer recommendations and/or local codes? �
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�ps Held at`� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tig t� psid psid psid
Leaked I Leakedl � Did not open � I Did not open I I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I ClosedTight I I psid psid psid
Test gauge used: Make/Model/��'r�7� / � g SN: '�.j�r� �-�S 6
Date Tested for Accuracy: �-- l$-� f��
Remarks:
The above is certified to be true at the rime of tesring.
FirmName �iC /^U e y^�Jl d-�--- Firm Address d�� �DO. �5 .r1/ • �6���
,
Certified Tester(pri nt)�U( TO,� �Yf�? Certified Tester(signatur
Firm Phone#��[—;����_Cert.Tester No ��� � Date I����_/.�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- Ciry Copy Yellow-Customer Copy Pink-Tester's Copy