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: � "�5�
CONTACT PERSON/PHONE: at
LOCATION OF SERVICE: -+-
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 ❑Reduced Pressure Principle-Detector
�DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
.
Manufacturer �„�.a� Model Number 2�R Size lH
Located At Serial Number l c���
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 �.y p,s�id Held at o�•Y� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight L9� 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 C Closed Tight❑ psid psid psid
Test gauge used:Make/Mode1���0-?-�-}�GJrt,, SN:Q+{!�{21�ro�
Date Tested for Accuracy: 5!�/((E,
Remarks:
The above is certified to be true at the time of testing.
FirmNamel)�.•.�bacaL F,�s ��,e��, Firm Addresst�f��,c ZSf�� . ' T3(_ �b$
Certified Tester(print)'�k..�`�T(��Certified Tester{signature)
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Firm Phone#21�.+�4y.3t9'�I Cert.Tester No.k�iPO�lZ9'iS Date B��1lv
*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