2016_1105 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:
CONTACT PERSON/PHONE: D�
LOCATION OF SERVICE• '�11�_ rl'1 I7'1��
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 duced Pressure Principle ❑Reduced Pressure Principle-Detector
ouble Check Valve C Double Check-Detector
lPressureVacuumBreaker �]Spill-Resistant Pressure Vacuum Breaker
'/ � ��
Manufacturer �� �J� I/1 J Model Number �S� Size�
Located At �TJ� q� � Serial Number � � ��
Is the assembly insta ed in accordance with manufacturer recommendations andlor local codes? -�5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held atZ -� psid Held at 2•� psid pened at Opened at Held at
irial Test Closed Ti htl� Closed Ti ht , psid psid psid
�g g
�� Leakedf � Leaked� Did not open '. i Did not open L' Leaked 1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight�.I psid psid psid
Test gauge used: Make/Model.���������S� SN: d���b �4�0�
Date Tested for Accuracy: �— CU — �
Remarks:
The above is certified to be true at the time of testing.
Firm Name ������i-°�rl ��Firm A ddress ��T �%.' '//���Oi�/���rS
�
Certified Tester(pr�nt) � �- aa^� Certified Tester(signature)
Firm Phone# �'� ���v� Cert.Tester No.� Dev 0?S 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