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: "i-5'
CONTACT PERSON/PHONE: a
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-Deteetor
�Double Check Valve ❑Double Check-Detector
�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �.�c,� Model Number�cr�c�� Size 1�
Located At Serial Number ��6�,�
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 Vaive
1 st Check 2nd Check
Hetd atb•� ps� Held at�.6 psid pened 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
Test After Held at psid Held at psid Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model,�p,�l� �{D-Zp(�-}�Jr�i SN:QH 1�12Yrc'}
Date Tested for Accuracy: 5�y/l!�
Remarks:
The above is certified to be true at the time of testing.
FirmName.t�,o�,•.a,,�bo,c� F��e ��e�-�ra�Firm Addresst���o,c 7�'�. �1►�r� T3(_ �6�
Certified Tester(print)�I1 � Certified Tester(signature)
Firm Phone#21'�.'�14N,319�1 Cert.Tester No.BPO�lL9y5 Date (�}�I(,o
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
*'�USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy