2016_1107 IRRtGATION 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: L�+ ;�,�.E��y.q�p, c�. 3
LOCATION OF SERVICE:��;)3� T�n� 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 ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �,r,e� Model Number��x�$ Size !�
Located At Serial Number l �O$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 Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held atb-� ps� Held at a� psid Opened at Opened at Held at
Initial Test Closed Tight Closed Tight psid psid psid
� � Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight 0 psid psid psid
Testgaugeused:Make/ModelArTr,�tp �b-2�1C?-�-�C�i, SN:�IyZ��c"�
Date Tested for Accuracy: 5'f�p
Remarks:
The above is certified to be true at the time of testing.
FirmName.L�uo�,..er,�bac� ��t ��e�, Firm Addresst�f� �'��.1A1o`�� � T5l '�a 68
Certified Tester(print)�L...,'T�Ibr- Certified Tester(signature}
i
Fum Phone#21'�.�LzIN,3tq�1 Cert.Tester No.3P(�IZ9LIS Date l_ 1/}�1!o
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**LTSE ONLY MANUFACTURER'S REPLACEMEI�IT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy