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/PHONE• �.,�,�� ��y a3o � 3
LOCATION OF SERVICE: �t1�4 L�6ehti,
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 �.►1�_� Model Number�(nEX�$ _ Size 1�
Located At Serial Number l 3 ci ��
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Val�e Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�o�ps� Held at�psid Opened 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
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�,�lp �O-z�-�!-kJr�i SN:QRLyZ�'Cc�
Date Tested for Accuracy: �'jl�p
Remarks:
The above is certified to be true at the time of tesring.
FumName��o�...o.,,�b�.c� F�e ��.�Firm Addresst���o�c 2��_Wn`�1�+Qc�� T3t �bS
Certified Tester(print)�►��d�- Certified Tester(signature) /
Firm Phone#21'�,�tt1N.31et'�I Cert.Tester No.3POOlL�t`1 Date f l��f to
*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