2016_1010 IRRIGATION DOMESTIC � FIRELINE
The following form mList be completed for each assembly tested. A sigued aild dated original
�nust be subn�itted to the public wate_ r siip�ier fo�;recardk�pin��ses� � / �
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BACKFLOW PREVENTION A SEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) f�
MAILING ADDRESS: -7 V��� � � �`i'� � � ���� �� ��`�L-��� • �� �'��
CONTACT PERSON/PHONE: O � — — 3 6(
LOCATION OF SERVICE: 2l�-�r o� • �0
The backflow pi-evention asseinbly detailed below has been tested and maintained as requireci by
comillission regulations and is certified to be operatii�g within acceptable parameters. •
TYPE OF ASSEMBLY
�Reduced Pressure Principle I�Reduced Pressure Priuciple-Detector
! iDoubleCheckValve flDolible Check-Detector
I IPressurcVacu�imBreaker �-1Spi11-Resistant Pressure Vacuum Breaker
i/ `�
Manufacturer ���� � Model Number �� � Size �
� o� �p�, 't�h��r S,:n ►L ,� 6 a� I 6
Located At �P�l O Serial Number
Is the assembly installed in accordance with manufacturer recotnmendations aild/or local codes? ��
Reduced Pressure Princi le Assembl Pressure Vacuuin Breaker
Double Check Valve Assembly
- Relief Valve Air Inlet Gheck Valve
a,6 1 st Check 2nd Check
Held at�'�psid Held 1t�'� psid C�pened at�' � Opened at Held at
�u�tial Test Closed Tightl I Closed Tight I I psid psid psid
Leakedf I Leaked! I Did not open '� I Did not open ! I Leaked'� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Openecl at Held��t
Rep�ir ClosedTight i 1 ClosedTight� I psid psid psid
Test gauge used: Make/Model��11�- ll1 5 T ��j,� SN: ��0 � �� V (
Date Tested for Accuracy: ���j�� �
Re�narks:
The above is certified to be true at the time of testing.
Firin Nan�e �i�'���k Finn Address � �� �-^�"� • ��•�01
S� � �`���/�X-7G�'� �•�
Certified Tester(print) ���� Cerrified Tester(signature)
Firm Phone# � � �� / —�Cert. Tester No.P ���� 6�7a Date ` � ��p�� �
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow- CListonler Copy Pink-Tester's Copy