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 MAlNTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) .
MAILING ADDRESS: '��
CONTACT PERSON/PHONE•�,�,�► ,��y G1'�p chA
LOCATION OF SERVICE: ��_=.,�tc�welc�,�C�
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
OReduced Pressure Principle �Reduced Pressure Principle-Detector
�dDouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �„�.ta Model Number�C�'R __ Size 1�
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 Assemb(y
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�ps' Held at o�•a( psid Opened at Opened at Held at
Initial Test Closed Tightf- Closed Tight psid psid psid
Leaked� Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Hetd at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C Closed Tight❑ psid psid psid
Testgaugeused:Make/Model�`� �O-��O-�Jc�, SN:�IyZ�Co�
Date Tested for Accuracy:�f4/(�
Remarks:
The above is certified to be true at the time of testing.
FirmName,�o,�1�c,c� -�'i�c �a�u�, Fnm Address�0 _ 9_ '�_lAb��+.�c1.�_� �6`d
Certified Tester(print)�1�...�dr Certified Tester(signature) �
Firm Phone#2t'�,'�l4'�.�v19`I Cert.Tester No.3PUOlZ9'�S Date f[/��f(a
*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