2016_1011 IRRIGATION `�/ DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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: ,�o l�_��Y'0��'�'S�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: S 0t�� r v`
The backflow prevention assembly detailed below has been tes ed an maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�1Reduced Pressure Principle �Reduced Pressure Principle-Detector
i Double Check Valve Double Check-Detector
C PressureVacuumBreaker -Spill-Resistant Pressure Vacuum Breaker
` /�- . f
Manufacturer t ` i i.� Model Number � � ����� Size_1�/�
, �
Located At�Ybr.�'� � Serial Number� s`j�;��G
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e-�
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��� psi Held at��psid Opened at Opened at Held at
Initial Test Closed Tigh ' � Closed Tigh psid psid psid
Leaked I�1 Leaked 1 Did not open I�'�� Did not open '�, Leaked I I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
` Repair Closed Tight I I Closed Tight I psid psid psid
Test gauge used: Make/Model (,V 1�/ !'��S SN: ���3/�5�
Date Tested for Accuracy: �— �g •—�`6
Remarks:
The above is certified to be true at the rime of testing.
Firm Name�/ (/'��5��-� Firm Address � �0 � 0 0 �� s
Certified Tester(pri nt) 1� � }'' ertified Tester(signatur
Firm Phone# �¢ ` b �� b��0 Cert.Tester Na ����� � Date ��—/��/ �
* TEST RECORDS MUST BE KEPT FOR AT LEAST THR E YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy