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: �'�
CONTACT PERSON/PHONE: r:��,��y.at'�p, m�a_ 3
LOCATION OF SERVICE: 1 Oa� �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 �7Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��„��� Model Number 2�� Size l�
Located At Serial Number �b L��
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 3�� psid Held at a7� psid Opened at Opened at Held at
Inirial Test Closed Tight� Closed Tight � psid psid psid
Leaked❑ Leaked❑ Did not open ❑ 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�����}-2�-}�J�i i SN:�{14 2S�fa�
Date Tested for Accuracy: 5�+�1(�,
Remarks:
The above is certified to be true at the time of testing.
FirmName��o.,�ba,e� F�c �e}�rr�r�Firm Address�0�c 2_2�`J�_V�o`�1R,�i��:�, �b`�
Certified Tester(print)'�1�._,'T���br- Certified Tester(signature)
Firm Phone#2t'�.'�L4W.�vl�t"•1 Cert.Tester No.k�iPOiDlZ9�iS Date I�� 1(�
*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