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: '�-S�
CONTACT PERSON/PHONE:�„���y ��9. dg �
LOCATION OF SERVICE: 1 O a �a�y..�lcy,�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.
. TY�E OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �.,1f� Model Number 2M�CXh� Size l�
Located At Serial Number l ��
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 Vaive
1 st Check 2nd Check
Held at 1�ps Held at�psi 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 Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ ClosedTight�J psid psid psid
Test gauge used:Make/Model ArTr,�`p �{O-2-�1C?-�-�G�i i SN:�ly 2�fo�
Date Tested for Accuracy: Sf�p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��o�.a.,�bac� F« ��um., Firm Addresst��$enc�1J����� �_ �,b'$
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Certified Tester(print)�1,..,�a�Idr- Certified Tester(signature)
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Firm Phone#2,1'�,'�1'�I.3tR�1 Cert.Tester No.k3PQalZ9`1S- Date 1_T�1(0
*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