2016 IRRIGATION � DOMESTIC FIRELINE
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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: �' / `��r=- �." v;=
LOCATION OF SERVICE: 7�'f ti�,�,���
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
�iReduced Pressure Principle 1Reduced Pressure Principle-Detector
�ouble Check Valve �Double Check-Detector
' ressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
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Manufacturer �'"li � ,'�J Model Number �f� Size
Located At /���-��,�c Serial Number �,�������
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? /��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at � ,� psid �d at�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight - psid psid psid
Leakedf ' Leaked 1 Did not open i 7 Did not open f" Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight 7 psid psid psid �
Test gauge used: Make/Model/�� /��J �^7`��-�.�`i_%�%�l/ SN: ��fG-'liLL�
Date Tested for Accuracy: � � ° ��—/�
Remarks:
The above is certified to be true at the time of testing.
Firm Name/�, ��a '.`�:l�"!,�r�����Firm A ddress �`G �f �-�.. /L,..� ����,.,�. �"%/i
/'- - �� _-_
Certified Tester(print) �-'�� ��� ,�-�—��''-Certified Tester(signature) �i� /������-�_
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Firm Phone#�?;-- 7�� =�����1 Cert.Tester No. �'� �`-�i/v � � Date
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**L1;�E ONLY MANUFACTURER'S REPLACEMENT PARTS
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W�'hite- City Copy Yellow-Customer Copy Pink-Tester's Copy