2016_1107 IRRIGATION DOMESTIC FIREUNE�
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-'b'
CONTACT PERSON/PHONE: L�e,,.�yP a�y,�13p. cmR.
LOCATION OF SERVICE:��25 �_T�,�,QjCrC�+
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 �t.,��� Model Number���h$ Size l�
Located At Serial Number �lo l 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�psid Held at��psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight 8� psid psid psid
Leaked❑ Leaked❑ Did not open Q Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight� psid psid psid
Test gauge used:Make/Model_�t��p-2€X"j-+1G�i.i SN:�t y 2��"�
Date Tested for Accuracy: Sfy/l{F,
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��a,..Q�„��.inc� �« ��,r,�, Firm Address���,c Z��1R,n�_�_�s TT�t" �(,$
Certified Tester(print)�I�..,�Iti� Certified Tester(signature)
Firm Phone#2i'�.�[�I�I,3tR'�1 Cert.Tester No.k�PQiDlZ94S Date lT�1 Ga
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**U5E ONLY MANUFACTURER'S REPLACEIVIENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy