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 PRE'VENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) .
MAILING ADDRESS: �
CONTACT PERSON/PHONE: 11.►r.� T ��y a3o c� �
LOCATION OF SERVICE:�'�1� L�he�h- .
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spiil-Resistant Pressure Vacuum Breaker
Manufacturer Q.,1� Model Number�Cn��$ Size l�
Located At Serial Number ����`7
�—
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Presswe Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at��p Held at��psi Opened at Opened at Held at
Initial Test Closed Tight� 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❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model 1�� �j0-2�-}���, SN:�I�Z��c'}
Date Tested for Accuracy: 5�*�_,/!T
Remarks:
The above is certified to be true at the rime of testing.
Fum Name�,o�•.� lx.,� ��� ��+ar.��Firm Address t�b�a,c 25�?�_UO;a��r�r-�-' ,�j, �6�
Certified Tester(print) 1..,���d�- Certified Tester(signature)
Firm Phone#21+1,y4�1.31R�1 Cert.Tester No.l' POOL�9`IS Date l���I lo
*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