2016_1107 IRRIGATIOIV 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/PHONE: T��:�,�, ,��y a3o c� 3
LOCATION OF SERVICE:�"l�{ L�Ioe�h-�,
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
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �t.,1c,� Model Number�c�c�8 Size l�
Located At Serial Number �3 l `��
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 Iniet Check Valve
1 st Check 2nd Check
Held at�_ps' Held at f7.�psid Opened at Opened at Held at
Initial Test Closed Tigh Closed Tight � psid psid psid
F��' 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�� �ilb—2pC�—��G'J`�i� SN:�]l�2YCc�
Date Tested for Accuracy: S/, N/!!p
Remarks:
The above is certified to be true at the time of tesring.
FirmName�,c�,..a�„�1�nc� F�e ��� Firm Addresst�� 9�'�_ �1„nr]�•� 'T�( �6�
Certified Tester(print)�1�..���id�- Certified Tester(signature)
Firm Phone#2,1�I,�L+-I�1.31°[�1 Cert.Tester No.$P�OlL9yS Date 1 /��I(e�
*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