2016_1107 IRRIGATION DOMESTIC FIRELINE_�C,_
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: � '�6'
CONTACT PERSON/PHONE: 1��.;�,�,�� ��y a3o �1 3
LOCATION OF SERVICE:� L� .
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 �.,1�� Model Number��$ Size lN
Located At Serial Number ��OL�O�
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Presswe Princi le Assembl Pressure Vacuur�o Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at`�-� psi Held at 3•� psid Opened at Opened at Held at
Initial Test Closed Tight Closed Tight � psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open L Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight L� psid psid psid
Test gauge used:Make/Model�,r,l��(�-2�1Cj-�i-�GJr�, SN:�l y 2�rc'}
T'
Date Tested for Accuracy: S�y�p
Remarks:
The above is certified to be true at the time of testing.
Fum Namel�,o�,�•.e,�,�bc,,� F�i ;c�,e�-�Firm Address t�Q Sd,c 25��_ � ?X �bB
Certified Tester(print)�1�,.,��Certified Tester(signature)
FirmPhone#21'�.'�1�1�1,3�R*� Cert_TesterNo.BPOOLL9yS Date l���fto
*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