2016_1107 IRRIGATION DOMESTIC FIRELINE_1C
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: '}{'
CONTACT PERSON/PHONE:_������y q3g �p 3
LOCATION OF SERVICE: l.Cn�?5 =„dr�G�_,•,•�Ic��
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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
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer +�,,,��� Model Number����'� Size l�
Located At Serial Number l�oa�cj
Is the assembly installe in accorda.nce 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 atQ•`r psid Held at�psid Opened at Opened at Heid at
Initial Test Closed Tighta� Closed Tight psid psid psid
�' ti Leaked❑ Leaked❑ id not open G 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 rJ psid psid psid
Test gauge used:Make/Mode1���stb-?�C7-��CJ��� SN:Q+{ty Z'Y('a'}
Date Tested for Accuracy: 5'f���p
Remarks:
The above is certified to be true at the time of testing.
Fnm Nazne,��..Q�,�ba,c� F�,�� ��,e�, Firm Address t�0�enc Z��.W�a`�±.4�e-�..�Tl( �,bB
Certified Tester(print)���Certified Tester(signature)
✓�
Firm Phone#_2,1+{,'{�-1W,3t9�1 Cert.TesterNo.3P(�OlZ9'�5� Date l_T�1(0
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE(?NLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy