2016_1104 IRRIGATION� DaMESTIC FIRELINE
The following fonn must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLO�V PREWENTION ASSEMBLY TEST AND MAINTENANCE R�PORT
NAME OF PV�'S: CITY OF COPPELL P�VS LD. #Q570Q40
(�uStOn1@i� ��
MAILING ADDRESS: V d/� ��o��5
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � � -7�——r��vl��
The backflaw preventian assembly detailed below has been tested and rrl�intained as required by
cammission regulations and is certified to be�aperating within acceptable pnrameters.
TYPE OF ASSEMBLY
�R duced Pressure Principle ``Redueed Pressure Principle-Detector
oubleCheck Vah�e 'Double Check-Detector
PressureVacuurnBreaker Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �� I�� V � Model Number ��O �G'T Size � �`
Located At ��s�-�� ��7'� Serial Number d �
ls the assembly�instafled in accordance�vith manufacturer reco�nrnendations and/or local codes" i—S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air lnlet Check Valve
1 st Check 2�d Check
Held at�psid Held aT,�..�psid Opened at Opened at Held at
Initial Test Closed Tighd� C[oscd Tight t� psid psid psid
Leaked ' Leaked Did not open Did not ppen ' ' Leaked
Repairs!
Materials
Used
Held at psid �Helci at psid
Test After O�ened at Opened at Hetd at
Repair Closed TighF� ' GosedTight�� �. psid psid psid
Test gauge used: MakelModel G�i'�f�i��S 5N:�S/S'����
Date�Tested for Accuracy: ��f �-���
Remarks:
The above is certified to be true at the time af'testing.
�
Firm Name �tJC,,p�s�'�� Firm Address Pb��,`������ �l �X�dD�
Certified Tester(�rint) ��S � Certified Tester(sigr►atur�
Firm Phone#�t F 6�� ��� Cert.Tester N I � a Date —
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Cnpy Yellow-Customer Copy Pink-Tester's Copy