2016_1111 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: O � v �� rr�cs� CZr✓
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
.iReduced Pressure Principle : IReduced Pressure Principle-Detector
'�ouble Check Valve 1 Double Check-Detector
��IPressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
/
Manufacturer CJa��!�rv S Model Number �S U Size �
'� � �4 Ss� S3 5
Located At f—�U�/f i/�4/l.� Serial Number
Is thE assembly installed in accordance with manlifacturer 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��� psid Held at�•� psid Opened at Opened at Held at
InitialTest ClosedTight'���� ClosedTight I psid psid psid
Leakedl Leakedl Did not open I I Did not open I Leaked' '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight'�J ClosedTight'i i psid psid psid
Test gauge used: Make/Model�f�Ce� �10�� ��'1 �/ SN:���� �� � �
Date Tested for Accuracy: �!oZ�l l/ �
Remarks:
The above is certified to be true at the time of testing.
Firm Name -s� -��� Firm Address � �a��A 5�V'�E'� ,S/¢-Cf"►5� ��
Certified Tester(pr;nt)���l�q�� �v�¢h�ertified Tester(signature)�_�.�L��i� ������
Firm Phone#� �� � �O�J`3�3�'� Cert.Tester No.��j �b 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