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: '�"S
CONTACT PERSON/PHONE: �
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
�C1'Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker QSpill-Resistant Pressure Vacuum Breaker
Manufacturer �l.►1� Mode]Number�C�p��$ Size l�
Located At Serial Number 13�70.2
Is the assembly install 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 a� p,s�iQ Held at�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight C� 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❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model/��tp �O-�b-�J`�� SN_QH l y 2��0�
Date Tested for Accuracy: Sf*�!/!G.
Remarks:
The above is certified to be true at the rime of testing.
Fum Name��,o�..Q,,,�bnc� F« ��r�.}�Firm Address t�Q$a,c 25��_ ,o�l�arl.�►,r TSt �6$
Certified Tester(print)�1�,..� Certified Tester(signature)
Firm Phone#21�1.'�1�1�1,31R'�I Cert.Tester No.BPf�OlZ9yS Date���!(c
*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