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: ��
CONTACT PERSON/PHC)NE_ 11a�;���y �t3p dR 3
LOCATION OF SERVICE: �r1I L�be.r}-�
The bacl�low 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 Presswe Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
DPressureVacuumBreaker QSpill-Resistant Pressure Vacuum Breaker
Manufacturer �t..1�� Model Number�(�[+�$ Size !H
Located At Serial Number L �o��_
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assemb(y
Relief Valve Air lnlet Check Valve
1 st Check 2nd Check
Held at�psid Held at `o� � psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight�.0' 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 I� Closed Tight❑ psid psid psid
Test gauge used:Make/Model�ne��p HO-ZGjb-�J��, SN:�t�{Z�Co�
Date Tested forAccuracy:�',f*�1��G,
Remarks:
The above is certified to be true at the time of testing.
Fum Namel�,o�•.or,�bc,c� -�i�+. ;c'd}r�'u�. Firm Address 1�Q&„c 25��_11� ml�arl.r.Z_?X �b`b
Certified Tester(print)��,.,�r,�r Certified Tester(signature)
Firm Phone#21'�,�t�ILi�31R'�1 Cert.Tester No.3POOlL9�) Date !!���1(0
*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