2016_1107 IRRIGATION DOMESTIC FIRELINE�X
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
{Customerj .
MAILING ADDRESS: '�'
CONTACT PERSON/PHONE: i��.;,���y a�o crfl �
LOCATION OF SERVICE: J�S'� �.�.a�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-Deteetor
�DoubleCheckValve ❑Double Check-Detector
JPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer +�t.�� Model Number�(�X�� Size IN
Located At Serial Number �(a 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��ps/id Held at�psid Opened at Opened at Held at
Initial Test Closed TightlY Closed Tight� psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materiais
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight� psid psid psid
Testgaugeused:Make/1Vlodel���p �p-2�j-�-k��, SN:�t42�fo�
Date Tested for Accuracy: Sf�p
Remarks:
The above is certified to be true at the time of testing.
Firm Namel��a�..a.,�bac� �,�s �o}e��Firm Address i�0 �'�� � � TX �6`d
Certified Tester(print)����(!,�- Certified Tester(signature)
Fum Phone#2,1'�.'t�1�),31R�-1 Cert.Tester No.f3Pt�ll94S- Date lT f Il�
*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