2016_1031 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: +. - . � u��� �. k
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle l Reduced Pressure Principle-Detectar
�louble Check Valve I �Double Check-Detector
1PressureVacuumBreaker i Spi11-Resistant Pressure Vacuum Breaker
��Manufacturer (.tW, �h t.v$ Model Number .�S� Size�__
Located At f�2U�✓1 +>�q-!1 Q Serial Number/'T SCYO y �� /
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? L '�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held a�% � psid Opened at Opened at Held at
Initial Test Closed Tigh�� Closed Tight,� psid psid psid
Leakedl 1 Leakedl ' Did not open ��I Did not open ' '� Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight_1 ClosedTight��I psid psid psid
Test gauge used: Make/ModelCvmf!�« �'7a �°w %/7 u SN��G'�/(o�'j `7
Date Tested for Accuracy: b'�o�y �I �o
Remarks:
The above is certified to be true at the time of testing.
FirmName.�� .1-���. Firm Address�Ga�2 �� 5 1/iC�r/ 5'/�C/�SL` �i�
Certified Tester(pr�nt)/'h �t/f��;� �� (; Certified Tester si natur � /� Gs1
� �i � � g � ��� ��� ��.
Firm Phone#g 7�2 — �'��-�7��f Cert.Tester No.�S �/� Date/O /1
* 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