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: � '�-6
CONTACT PERSON/PHONE: h;�� ���i �30, c�t .�
LOCATION OF SERVICE: c,l�Q� L�6e�k-�,
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufachuer �.,�.1_� Model Number 2(�7$ Size lµ
Located At Serial Number1�-86�a3
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Val�e Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at3,� p 'd Held at�.o�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Test After Held at psid Held at psid Qpened at Opened at Held at
Repair Closed Tight❑ Closed Tight� psid psid psid
Test gauge used:Make/Mode1S���O-?.�Jp-�-kJ'��, SN:�ly2Y�a�
Date Tested for Accuracy: 5f�l�llp
Remarks:
The above is certified to be true at the time of tesring.
FirmNameL��o�...o�„�bc.,r� F�e. �o},r�,or, Firm Addresst'�O�. Z�- .t1u � ��T�( �b'S
Certified Tester(print)�1����_Certified Tester(signature)
Firm Phone#21+�,�LM�I.31�'�1 Cert.Tester No.�3POOlL9`IS Date f���I!v
*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