2016_1107 IRRIGATION 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:
SACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) ,
MAILING ADDRESS: '�
CONTACT PERSON/PHONE-�n;�p �1y Qt�O c�l
LOCATION OF SERVICE: �l b�{,� v �,�^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 A.�� Model Number���$ Size l�
Located At Serial Number��, 1 d O
Is the assembiy 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�.� id Held at �.� psid Opened at �pened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
LeakedrJ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Heid at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model/�1���b-2�jC7-�-�GJr�. SN:Q�{!�{2���
Date Tested for Accuracy:�' �1/l p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��o�•.a.,�bac� -ri�i ��u�. Firm Addressi�0�cnc 2�Wo��.� • TX_ �,b$
Certified Tester(print)-C�..,`�ar r Certified Tester(signature)
Firm Phone#2.1'�,�l�l�)�3l9'i Cert.Tester No.?POOlZ9y5 Date t��1 lrlr.►
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer�opy Pink-Tester's Copy