2016_1107 IRRJGATION DOMESTIC FIRELINE�C,_
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: "�-5'
CONTACT PERSON/PHONE• L�„�� .E� ��y at'3p crA 3
LOCATION OF SERVICE: ��y 5 =„,����s.�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.
. TY�E OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �l..1e� Model Number�C�CXh� Size IH
Located At Serial Number �lo 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�psid Held at �,O psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
� t� Leaked❑ Leaked❑ Did not open C Did not open ❑ Leaked❑
Repairsl
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model�� �J(�-2.�b-f�CJ�i, SN:�t42��c'}
Date Tested forAccuracy:�'�,!/l(F,
Remarks:
The above is certified to be true at the time of testing.
Firm Namel��o�..ar,�,lha.c�► F�� �Cd4rs�'u�, Fum Address fi��$o,c 25�"}_Wio�ao�_1r,nc�_TS( �b$
Certified Tester(print)�.1,..,�r,�- Certified Tester(signature)
Firm Phone#21+�.�tLIW,3l9'�1 Cert.TesterNo.3PL�M`>lZ9yS Date lT f I(c,
*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