2016_1107 IRRIGATION DOMESTit FIRELINE�_
The following form must be completed for each assembly tested.� A signed and dated originai
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
(Customerj
MAILING ADDRESS: � �i
CONTACT PERSON/PHONE: L�e„�R���y.°t'�p. �t 3
LOCATION OF SERVICE: 1r� �.����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 OReduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �,,,<<_� Model Number 2tn�b[�R Size l�
Located At Serial Number � 56�"1 �
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 1-`E ps d Held at �� psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight�� psid psid psid
Leaked�7 Leaked❑ Did not open � Did not open ❑ Leaked�
Repaiis/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C Closed Tight� psid psid psid
Test gauge used:Make/Model ��� y(�-2.�X�-�GJr�, SN:�Z+{ly2Yfo�
Date Tested for Accuracy: �'fy,/l�
Remarks:
The above is certified to be true at the time of testing.
FirrnNamel��o�•.z►,�bac� -�'i�i ��e�-u�, Fum Address t�'O�onc 25�� .W��;•�s� TX^�b$
Certified Tester(print) ►,.�`���,� Certified Tester(signature)
Firm Phone#?,��,'�4'�,319�i Cert.Tester No.3PQ�ll9'i5 Date 1�,�1 to
*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