2016_1107 (2) 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: i�c+ ;�,S��y.�t�p. thA 3
LOCATION OF SERVICE:�,( l2 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
�7DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufachuer �t„��� ModelNumber��'� Size 1�
Located At Serial Number � Co� ��
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 a• l psid Held at�-D psid �pened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open C7 Leaked❑
Repairs/
Materials
Used
Neld at psid Hetd at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight 0 psid psid psid
Test gauge used:Ma1ce/Mode11����p-?�j-�-�GJr�, SN:QI{!�{25�1'c'}
Date Tested for Accuracy: �',�'��
Remarks:
The abave is certified to be true at the time of testing.
Firrn Name.l�,a,•.Qr�bac� F�� ��,�,oh Firm A ddress t��$enc ��`}_Ub`���1.�►,r �( �a �,�
Certified Tester(print)�'GG1.�' ..,`'I�T(��Certified Tester(signature)
Fum Phone#21'�,�Ls{W,3tR'�1 Cert.Tester No.r3P�[Z_9'�S Date /}�I(c�
*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