2016_1111 IRRIGATION v 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:
LOCATTON OF SERVICE: �� C� � v w��n/(¢ Cir�J
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
f Reduced Pressure Principle I 'Reduced Pressure Principle-Detector
'l�ouble Check Valve '�� I Double Check-Detector
[1PressurcVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
3
Manufacturer �1 �" � �''� 5 Model Number � S � Size�
Located At ��-�� �/�'��� Serial Number /? SS ��� �
�-
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? i G`
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
lnitial Test Closed Tight�� Closed Tight�I— psid psid psid
Leakedf�I Leakedl ' Did not open ''� I Did not open I Leaked��� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opencd at Opcned at Held at
Repair Closed Tight�, Closed Tight��1 psid psid psid
�
Test gauge used: Make/Model�'''�����O ��a�/h� SN:��dJ Gt' �l� `7 �
Date Tested for Accuracy:�/B�' / �
Remarks:
The above is certified to be true at the time of testing.
Firm Name�� .Z'7� Firm Address v G���'`�S lt/'�(,�-�.� -siQC/�Sb ��/
✓17 rC i-�'1�� L �VZ. �)C�
Certified Tester(pr:nt) Certified Tester(signature) :.�'����� -��z�
Firm Phone#����� ���✓� 73�� Cert.Tester No.�S �'!(7 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