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: � '}�i
CONTACTPERSON/PHONE: L�e,,.��,Q ��si.at�vp. chFl 3
LOCATION OF SERVICE: ��� v C,�,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
�7`DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �,,,,�f� Model Number 2�A Size lN
Located At Serial Number ��t O�
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�psid Opened at Opened at Held at
Initial Tesk Closed Tight'� Closed Tight psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at gsid He}d at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gaugeused:Make/Model_��,�sfO-2QC�-+jG��, SN:�1yZYlo'}
�
Date Tested for Accuracy: ��/�{f l rp
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��•.a�bo,,c� ��i ��zc,�Firm Addressi�0 . �_Wa`�4,ae� TA'�b� "
Certified Tester(print)�1,T..,'�aT�_Certified Tester(signature)
Firm Phone#2t'�,y�1'�I.3tq� Cert.Tester No.3PO�LZq�IS Date �T�I La
*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