2016_1107 IRRIGATION DOMESTIC FIRELItdE�
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 MAIlVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) .
MAILING ADDRESS: ��
CONTACT PERSON/PHONE:�,o„�,a��y at�? m�1 3
LOCATION OFSERVICE: 1Q33 v�r..�l�•y,�a
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
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer A.,��� Model Number 2t�(''X.�� Size !�
Located At Serial Number � ��?3�
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembty
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at a� psi Held at o7a psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Heid at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Testgaugeused:Make/Model�t,p yb-?-�.i(�-�-�C��. SN:�ty2�fc'�
Date Tested for Accuracy:�'f,t/((p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel�,a,•.Qr�„�1oa,c� -ri�s �o}+r,�ru�, Firm Addressi��$c�,c 2'Sn�_ ���TX '�b�
Certified Tester(print)��,r- Certified Tester(signature)
Fum Phone#21'�.�L�t�),�vt9'�i Cert.Tester No.k3PObLLq�iS Date l��!tca
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**LJSE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yeliow-Customer Copy Pink-Tester's Copy