2016_1028 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 purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) n
MAILING ADDRESS: �11 /C�S� ������,� 't� �g�0
CONTACT PERSON/P�IONE:[%�;t"��(,,zf�. �y�— �}.(,7� CXF PS
LOCATION OF SERVICE: ��'j S�v�v �c.�I(-e rc+��
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
�l ced Pressure Principle ❑Reduced Pressure Principle-Detector
ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
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Manufacturer �./C�I-�' S Model Number�p) Size�_
Located At N�.✓ C�r�v�P.r �3� r�f�jJ Serial Number /1/`�
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
]st Check 2nd Check
Held at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed TightLS� Closed Tight I� psid psid psid
Leaked���7 Leaked❑ Did not open ❑ Did not open ❑ Leaked�:I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model M��_�r��n�.�►� `��l-5 SN: ��p_�j q �.�3
Date Tested for Accuracy: �— l�� 1(�
Remarks:�v�.;�4 +r, c,r ; n�F� ,Q\01�'�
The above is certified to be true at the time of testing.
Firm Name�,`rz�- L���, ����� ��er'c�irm Address �,./, �� �
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Certified Tester(print) �' �b 5 Certified Tester(signature)
Firm Phone# GI 7 d--.�1.4- �-13 a0 Cert.Tester No.i�f�n�13�6�� Date ���(,�
*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