2016_1009 IRRIGATION ��C 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 LD. # 0570040
(Customer)
MAILING ADDRESS: ��CQ C� �Z�C� ��✓1�v��l
CONTACT PERSON/PHONE: �37:�.11�� �— �1��2 �
LOCATION OF SERVICE: �
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
f-�ble Check Valve �_]Double Check-Detector
�IPressureVacuumBreaker �'�Spill-Resistant Pressure Vacuum Breaker
Manufacturer�'�,,e'l.�N"�� Model Number �'�� Size�
Located At „/�►-+'�� Serial Number ��'�cT � � "t0 �
Is the assembly instal ed 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 at�psid Held at��sid Op ned O ed e
Initial Test Closed Tight�. Closed Tight .�� psi F�"� p i
Leakedl ' Leaked' 1 Did o D'd no pen � I Leaked' I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I 1 ClosedTight! I psid psid � psid
Test gauge used: Make/Model ' SN: �e�"2/�_
Date Tested for Accuracy: '��—, '—� �
Remarks:
The above is certified to be true at the time of testing.
Firm Name��� ��� Address s
Certified�ester(print) ��'� Certified Tester(signature)
Firm Phone# ���� ��� Cert.Tester No. � � � � Date '�����
* 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