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:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: ��
CONTACT PERSON/PHONE:�,��t+ �.1�i at�O crA 3
LOCATION OF SERVICE: 1Q�6 �tp�,�elC��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 OReduced Pressure Principle-Detector
�fDouble Check Valve ❑Double Check-Detector
JPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �„R�a Model Number�_C��XhR Size l�
Located At Serial Number �(o a�o�.�
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Presswe Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�_psid Held at 3•� psi Opened at Opened at Held at
Initial Test Closed TightC`� 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❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model��,p �JO-2ab-�Jri. SN:�l�1 Z��a'}
Date Tested for Accuracy: Sf��
Remarks:
The above is certified to be true at the time of testing.
Firm Namel��o.,..��,,,�bac� �,�e. ��u�., Firm Address t�0$c�. 2�'�-. 1.�c�t_TX �6`d
Certified Tester(print)�1�...�Ie� Certified Tester{signature)
Firm Phone#2i'�,'�+�i�i,?v19'i Cert.Tester No.3Pbt`+lZ9yS Date �����1(o
*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