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: � C c�ri/( r� �rtJ
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 f IReduced Pressure Principle-Detectar
I �� ouble Check Valve ��1 Double Check-Detector
� �-IPressurcVacuumBreaker � 1Spi11-ResistantPressure VacuumBreaker
!
Manufacturer�if�;r� �j ��'�` S Model Number �SC� Size�
�
Located At ��n( �/r¢�LD Serial Number/�.���o �o7Q
Is 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 a� �psid Held a� �psid Opened at Opened at Held at
Initial Test Closed TightrJ� Closed Tight r�� psid psid psid
Leaked�. 1 Leaked'� I Did not open ��I Did not open I � Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight��] Closed Tight I psid psid psid
Test gauge used: Make/Mode - °- vr1 � t� SNQ(��-! ( �e c7 '
Date Tested for Accuracy: Is
Remarks:
The above is certified to be true at the time of testing.
Firm Name��� .��� Firm Address� li�v2 ��S i/�CG•/ ����5�� l/c
����u ���
Certified Tester(pr�nt) Certified Tester(signature�_���___ �_
Firm Phone# �����,�—Cert.Tester No���O Date // t � (
* 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