2016_1107 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: � "�'S'
CONTACT PERSON/PHONE: Qt
LOCATION OF SERVICE: L O
The backflow prevention assembly detailed below has been tested and maintained as required by
cotnmission regulations and is certified to be operating within acceptable parameters.
. TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�DoubleCheckValve �7Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �.�� Model Number���$ Size lH
Located At Serial Number
Is the assembly installe 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 o7� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairsl
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight 7 psid psid psid
Test ga.uge used:Make/Model�pl`p H�-2.p�7-�-fCJ=� SN:�l42�fc'}
Date Tested for Accuracy: Sj�p
Remarks:
The above is certified to be true at the time of testing.
Firm Name1��.•.Qr�]]bac� F',�c ��es�;r,r, Firm Address t�0�c„c 2—'S7_)�_11J�o�m.�s�,� �a 65d
�
Certified Tester(print)�1ti.q�bP Certified Tester(signature)
Fum Phone#2,1�,'�i�iy.31R'•i Cert.Tester No.3PQt9lZ9�IS Date T /��I(r�
*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