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: "i'S�
CONTACT PERSONIPHONE: 11p�;�,�� ��y �3O �1.
LOCATION OF SERVICE: �y�t L��` _
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regalations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
C1PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Q.�� Model Number�(ri�,�5 Size l�
Located At Serial Number F�CS�]��2 _
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
ReliefValve Air Inlet Check Valve
1 st Check 2nd Check
Held at�ps' Held at�psi 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/
Materisls
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/Mode]��yO-21�b-�-kJr�, SN:�l y Z��c'}
Date Tested for Accuracy: .5/, 41/l fp -
Remarks:
The above is certified to be true at the time of testing.
FurnName�,o.,..o���bac� ��s �o��•. Fum Addresst�� ��. � � � • TX �b�
Certified Tester(print)�1�N�V I�,�- Certified Tester(signature)
t
Firm Phone#21'l,y�-t�l,�1tt'�) Cert.Tester No.3�lL9'� Date /��f(o
*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