2016_1107 IRRIGATION DOMESTIC FIRELIIVE�_
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 M.�NTENANCE REPORT
Nt�ME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: '�-5'
CONTACT PERSON/PHONE: �i�p ��y a�o c� 3
LOCATION OF SERVICE: LO����C,�,CLo
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 Presswe Vacuum Breaker
Manufacturer �„�.c� Model Number 2��i Size 1�
Located At Serial Number �(o�C3 �
-�
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 ato�•Co ps' Held at 3a psid Opened at Opened at Held at
Initial Test Closed Tight Closed Tight psid psid psid
Leaked❑ Leaked❑ id not open 0 Did not open ❑ Leaked❑
Repairs/
Materials
Used
Heid at psid Heid at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight� psid psid psid
Testgaugeused:Make/Model�tp <jQ-?�j-�-�CJr�, SN:�ty2��c'}
Date Tested for Accuracy: " f�P
Remarks:
The above is certified to be true at the time of testing.
Furn Name1��o,,..�,�,�1aac� F�,�t ��+r,�u�, Firm A ddress i�0�nc 25t��_ �„ae1.�.t_TX �b`b
Certified Tester(print)�k`�a((�_Certified Tester(signature)
Fum Phone#2,1'�,'�l�t'1.�v1�'� Cert.Tester No.k�iPOt`�lZ-q`�IS Date l�'} 1(0
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**LTSE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy