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: �'
CONTACT PERSON/PHONE•�,,�,������i a3o t� �
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
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �.,1�� Model Number�(ri�t7g Size In
Located At Serial Number � � 0 I S
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�_p d Held at��psid Opened at Opened at Held at
Initial Test Closed Tig� 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 ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model�� �O-?�X�-�-�G'�� SN:Q+�l y 2�Co�
Date TestedforAccuracy: 5'/�l/((p
Remarks:
The above is certi8ed to be true at the time of testing.
Fum Namel�,o�•.or,�bc.,r� F�s ��u�. Firm Address t"�Q _ ��� .Wn��1.�z�1.�.� TX ��,�
Certified Tester(print)�1�.�,� Certified Tester(signature)
Firm Phone#21'1,''�1�1�i,3tR'�1 Cert.Tester No.3�lL9yS Date E�}�1(r�
*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