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:
SACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D_ #0570040
(Customer)
MAILING ADDRESS: "�'b�
CONTACT PERSON/PHONE: i�e.r,i,����'�f.°t3p. �.
LOCATION OFSERVICE: 166� ��o�,�(c��p-
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 +�„�,f� Model Number��C�Ch� Size I�
Located At Serial Number �� �Z o2-3
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 o�.�o psid Held a�-� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight L psid psid psid
Leaked❑ Leaked❑ Did not open C Did not open ❑ Leaked❑
Repairs/
Materials
Used
Heid 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_�t��p-2�1b-�tGJ��, SN:�l�{2��0�
Date Tested for Accuracy: 5/:�l/rrp
Remarks:
The above is certified to be true at the time of testing.
Firm Name1��,•.Qr,�bc�c� F�',« ��,rw, Firm A ddress t�f� 7�Zh�.We.�ao.��ar�.��,�(, �bB
Certified Tester(print)� �..,�y�Certified Tester(signature)
1
Fum Phone#21'�.'�tLl.319'� Cert.Tester No.�ki��Z9yS Date l 1 l'��i(a
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**iJSE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy