2016_1107 IRRIGATION DOMESTIC FIRELWE�
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 PREVENTI�N ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #�570040
(Customer) .
MAILING ADDRESS: '�'S
CONTACT PERSON/PHONE: �
LOCATION OF SERVICE: L�
The backflow prevention assembly detailed below has been tested and maintained as requued 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
Manufacturer bt.,1� Model Number�c��Xh$ _ Size 1�
Located At Serial Number �tS (`7��
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuura Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at y-� psid Held at �•�' 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
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model��� �10-Zpp-{-kJ`-�, SN:�ly2�fo�
Date Tested for Accuracy:�'f�P
Remarks:
The above is certified to be true at the time of tesring.
FirmName.l�,ov.Q.,�l�o,,�� -ri�i ��+e�-�Firm Address�f��o�7�t��_ � `�3C �b`b
Certified Tester(print)�1�..��„I��Certified Tester(signature)
Firm Phone#2!'�,�t�1�1,3t�t'•I Cert.Tester No.BPOC�lZ9yS Date 1���
*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