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: "�6�
CONTACT PERSON/PHONE: q
LOCATION OF SERVICE: O
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„�� Model Number�n��$ Size I�
Located At Serial Number �b0(CJ
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��psid Held at�psid Opened at Opened at Held at
Initial Test Closed TightB� Closed Tight psid psid psid
Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
Repairs/
Materiais
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Testgaugeused:Make/Model��lnr,l� �d-?�pD-+�cJr�� SN:�1�12��c�
Date Tested for Accuracy: Sf�l/1 T
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��o�,..a.,,�bn�k -�`i�i �a4r�;e�, Firm Addresst�0�o,c 2�5t`�� � TX�516�
Certified Tester(print)`�l���r- Certified Tester(signature) �
Firm Phone#2l'�.N�Iy,319'�1 Cert.TesterNo.3POOlZ Date l l/��I!o
*TEST RECORDS MUST BE KEPT FOR AT LEAST THItEE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy