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: �7 7 � L u�wG� A�r�l
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
I Reduced Pressure Principle �Reduced Pressure Principle-Detector
�ouble Check Valve � !Double Check-Detector
IPressureVacuumBreaker `- Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �t l� (�t,y� Model Number,��p Size 7�/
Located At l`�v��I�/f��d Serial Number��S�d��
Is the assembly installed in accardance with manufacturer recommendations andlar 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 a�''� psid Held at a� � psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight � psid psid psid
Leakedi � Leaked'.�l Did not open 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��1 Closed Tight� I psid psid psid
�
Test gauge used: Make/Mode1C(�rs'!� �i�' U- cJ SN:(J�p(>�/ IpCj a
Date Tested for Accuracy: � � /
Remarks:
The above is certified to be true at the time of testing.
Firm Name �� � Firm Address�� ��9 5T!/'i C'�/ S/�L%fr�f `f
/.yl���I c'.L �v2�i C � //�
Certified Tester(prtnt) Certified Tester(signature) ��-i-����G�+f`il
Firm Phone# / ����U'�73� Cert.Tester No.�S al� Date �� ��/ 1 L
*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