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 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:
LOCATION OF SERVICE: G' c....i-v`T�v s s?�
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
C=Reduced Pressure Principle I 1Reduced Pressure Principle-Detector
�k3ouble Check Valve I '��Double Check-Detector
I �PressureVacuumBreaker f�ISpill-Resistant Pressure Vacuum Breaker
/ ' / �
Manufacturer c.,z/E �i �/ ��S Model Number ��� Size�
� ,/� f
Located At �2E"1n/ � �i42� Serial Number/7.�s(� 5 �'1oZ
Ts 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
1 st Check 2nd Check
Held atl ' �psid Held af't�� U psid Opened at Opened at Held at
inirial Test Closed Tightf�l� Closed Tight.%3d�' psid psid psid
Leakedf I Leakedl' Did not open I I Did not open � I Leakedl '�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I Closed Tight' l psid psid psid
Test gauge used: Make/Mode1�0 ,� "�p 40��� � lJ' SN:��U�-C ( �/' C! 7
Date Tested for Accuracy: �°7 l
Remarks:
The above is certified to be true at the time of testing.
Firm Name � �� -��"�� Firm Address� �v7� L��S� i/'oC..`-�v 5����SG` ����
�
Certified Tester(print)�����F�L l-�wl h�-`Certified Tester(signature)
� Firm Phone#�7�- ��(����3�/ Cert.Tester No.�S ��l Date � �i
* 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