2016_1026 (2) 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: t S$O �o��� Wesl� g)�� , cQp�c� ,Tic �7sc�►q
CONTACT PERSON/PHONE: ��►�
LOCATION OF SERVICE: I S?, I�a i n�. �/c��- F�1���
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
'�DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker !�Spill-Resistant Pressure Vacuum Breaker
Manufacturer � � 1� Model Number � 5� Size � �,
Located At rV o�' S 2►'�r�nr.c.¢_. Serial Number �.7 ds��� 1
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��s
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
� 1 st Check 2nd Check
Held at�'�psid Held�,o psid Opened at Opened at Held at
Initial Test Closed Tight�J Closed Tight .� psid psid psid
Leaked❑ Leaked�] Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model����1�'PS.�I$��"s`���� SN: (jq�c1�7 Z�
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
FirmName �y�`�,�j Firm Address ��� SCec�cY �ltl ►�c� , '��/Q`!
Certified Tester(print) �, �w���j /��C., Certified Tester(signature
Firm Phone# ��'G��� 7?�� Cert.Tester No. 3 p����1� Date lo - 2�- I(a
* 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