2016_1107 IRRIGAT�ON DOMESTIC FIRELINE�_
The following form must be completed for each assembly tested.�A signed and daxed original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTIOIV ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
• (Customer) .
MAILING ADDRESS: '�'
CONTACT PERSON/PHONE: ' tt
LOCATION OF SERVICE: � y .n����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
�7'Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer a1„�t� Model Number�CnC'X�)� Size l�
Located At Serial Number ���`��
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 ato�O� ps d 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❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model�pf��(�-2�'j-f-�GJr�, SN:��y2'1YCa�
Date Tested for Accuracy: Sf�l/l G
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��o�•.�.,�1�e,ca► F�s �a4r�r�, Firm Addresst�O 7�t`��.Wo.x�L+nc1.��_T5(, �b`b
Certified Tester(print)�1,..��a F��- Certified Tester(signature)_ —
Firm Phone#2l�,'�tl'�),319`� Cert.Tester No.r3POOlZ9yS Date (t/��I ld
*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