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: '�5
CONTACT PERSON/PHONE: ��p �ly a3a. c� 3
LOCATION OF SERVICE: I�1'�- T.�.ar,Rtaa�cr�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 �,,,��� Model Number ��)'Q� Size l�
Located At Serial Number� �o� A��
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 o1-g psid Held ata?�ps/id Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight L'� psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Hetd at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model���s�0-2�C?-��CJr►. SN:Q+�t y Z��o'�
Date Tested for Accuracy: S1�1/l�p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��,.,Qral�u� F�t ��u�. Firm Addressi�� 2_'S�`J'�� m�c��_T�C �5�b`�
Certified Tester(print}�k�f(�_Certified Tester(signature)
Fum Phone#21+�.'�l�l'�{.31q�1 Cert.Tester No.3P(�i`3lL9NS Date l /_}�1(0
*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