2016_1107 IRRIGATIOfU 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 ASSEII�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) ,
MAILING ADDRESS: �5
CONTACT PERSON/PHONE•�����y "t'3p ct�A 3
LOCATION OF SERVICE:�Q��=..,�t_c�c��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 �M�� Model Number�t�R Size l�
Located At Serial Number lS�6a
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�_psid Held at �� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight liY psid psid psid
Leaked❑ Leaked❑ Did not open L� 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�10 �O-2�-�CJ`�►� sN:Qy�y Z�b�
Date Tested for Accuracy:�'�'��
Remarks:
T'he above is certified to be true at the time of testing.
Firm Name,��e�..�,r,�loo�c� �,�e. �`�,e�-u�, Fnm A ddress t�p . ZSf)�. 1�c�_� �b�
Certified Tester(print) 1�,,.�w�(�,�- Certified Tester{signature)
Firm Phone#2t�.'�14�f.3t�'� Cert.Tester No.3P(9d1Z..9`1S Date f I���I4�
*TEST RECORDS MUST BE KEPT FOR AT LEAST THR$E YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy