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:��p ���i a3p � .�
LOCATION OF SERVICE: �
The backflow prevention assem� iled 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
❑PressureVacnumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �1.,R�� Model Number 2(,�h� Size la
Located At Serial Number 1 fo 1 r fo
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�•a� p - Held at�psid Opened at Opened at Held at
Initial Test Closed Tigh J Closed Tight El� psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked7
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����p-2pb-�CJ`��� SN:�{t�12`I���
Date Tested for Accuracy: 5f�,p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��o�..a,.,�loac� F',�e �s}r�r�Firm Address�� 25D� _ � ��'S16`$
Certified Tester(print)''�1�...�1,��- Certified Tester(signature) !
Firm Phone#21'�,'�IW.�v19'�I Cert.Tester No.k3POt9lZ9`IS Date (T�!fo
*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