2016_1010 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 purpo,�ses: � � _� �� � � � �
P�r�� �-
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040
(Customer) \ �
MAILING ADDRESS: ��� � ��,6.�4�Cn C� ����-- ���
CONTACT PERSON/PHONE: 1�
LOCATION OF SERVICE: p.� � rOVe- a-�
The backflow prevention assembly detailed below has been tested and maintained as re � d by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
7Reduced Pressure Principle [ Reduced Pressure Principle-Detector
-J Double Check Valve ��Double Check-Detector
-1PressureVacuumBreaker I 'Spill-Resistant Pressure Vacuum Breaker
,q /� \ \1
Manufacturer �C/��� Model Number ��✓�7Yti� Size 1
Located At �`���k �r� �k �'�al Number � � � J � �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?� �
Reduced Pressure Princi le Assembl Pressure Vacuum B eaker
Double Check Valve Assembly �
� Relief Valve Air Inlet Check Valve �
1 st Check 2nd Check
�� Held at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Ti ht�� I Closed Ti ht '�� I psid psid psid
g g
Leaked� Leaked�l. Did not open I Did not open I Leaked
Repairs/
Materials �� �� ��
Used �
Held at ' psid Held at • psid
Test After � Opened at Opened at Held at
Rep 'r Closed Tight� Closed Tight�, psid psid psid
�
Test gauge used: Make/Model �'�S � SN: � �6��� ��
Date Tested for Accuracy: � �
Remarks:
The above is certified to be true at the time of testing.
Firm Name�1�,���� J� Firm Address �, �0 � � �'"�� '`�Cl' S�' � " I
5�
Certified Tester(print)� � ���Certified Tester(signature)
Firm Phone# �L�"J��`� � O S b Cert.Tester No.D�O��`� �� Date '�� � � � "' � b
* 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