2016_1107 IRRIGATION DOMESTIC FIRELINE_�
The foltowing 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: '�-5'
CONTACT PERSON/PHONE:L���'��y at3p c�q �
LOCATION OF SERVICE:�'��,,�C., 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 �t.,1E� Model Number�t�X�$ _Size l�
Located At Serial Number �� I�b
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 tnlet Check Valve
1 st Check 2nd Check
Held at�,,4 p d Held at o?-j� psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight � psid psid psid
Leaked❑ LeakedG 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❑ Closed Tight G� psid psid psid
Test gauge used:MakelModel,��� �10-?.�-�:J��.i SN:�I�ZYfc�
Date Tested for Accuracy:�'f��
Remarks:
The above is certified to be true at the rime of testing.
FumNamel��o�,..a�„�1x,c.1L ��i ��+r�-�r�, Firm Addresst��� ���- . �b+Q�1.�T1t �6S
Certified Tester(print)�1,.�`���- Certified Tester(signature)
Firm Phone#2J'�,'�44'�1.3tR'�f Cert.TesterNo.BPOC�IZ_9� Date l 11��l10
*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