2016_1107 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)
MAILiNG ADDRESS: '�5�
CONTACT PERSON/PHONE: q
LOCATION OF SERVICE: �`2
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
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�'Double Check Valve ❑Double Check-Detector
;�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer A.h� Model Number�_C�C.�[7$ Size l�
Located At Serial Number C���a
Is the assembly installe 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��id Held at�.�psid Opened at Opened at Held at
Initial Test Closed TighYC`� Closed Tight '6� psid psid psid
Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight�J psid psid psid
Test gauge used:Make/Model�,e�� �p-2�-�kjr�,� SN:�1�12�6'}
Date Tested for Accuracy: ;$'f��
Remarks:
The above is certified to be true at the time of testing.
FirmNamel�ro�..or,�loc.�� -r,�� ��,�Firm Address t���C,c��i`)}�_11�m1„or1.�. Tf' �b�
Certified Tester(print)�1�..,��� Certified Tester(signature)
Firm Phone#?.!'�.�i4y,31�i'�I Cert.Tester No.�POOlL9'�IS Date !_T�1 to
*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