2016_1107 IRRIGATION DOMESl'IC 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: �'S�
CONTACT PERSON/PH�NE: 11������y �t3p � 3
LOCATION OF SERVICE:1�b L�be�h-�
The bacicflow 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�M�X�$ _Size t�
Located At Serial Number �3 c?��
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
]st Check 2nd Check
Held at �.a� p�id Held at �U psi Opened at Opened at Held at
Initiat Test Closed TightJ� Ciosed Tight psid psid psid
LeakedC 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❑ psid psid psid
Test gauge used:Make/Model�rr,l� �b-2�1b-+�CJ'�'� SN_�1�2Yfc�
Date Tested for Accuracy: 5��p
Remarks:
The above is certified to be true at the time of testing.
Firm Name i)��..,a,��]� ��t �?�,r�-�.Firm Address t�f��c„c 25��_ � �, �ta�
Certified Tester(print)�11���br- Certified Tester(signature)
✓,
Firm Phone#?_f'�,'{�i�l,31q41 Cert.Tester No.kiPQOlL9yS Date !�1'��P tra
*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