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: L1p,..::o „ ly �3O tvR
LOCATION OF SERVICE:��� L�be�� .
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 OSpill-Resistant Pressure Vacuum Breaker
Manufacturer A.,1c,� Model Number�C+�X,� Size (�
Located At Serial Number � �D( �
Is the assembly installe in accordance with manufacturer recommendations andlor local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�_psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�Y 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 0 Closed Tight❑ psid psid psid
Test gauge used:Make/Model�� �{O-2�-}�5� SN:QH t�2��c'�
Date Tested for Accuracy: 5, �lll�,
Remarks:
The above is certified to be true at the time of testing.
FurnNamel�,o�..a�„�bac� ��c ��a�. Firm Addressi�f� _ ���-.U►_1����� Tj( �6`b
Certified Tester(print)�t� � Certified Tester(signature)
U
Firm Phone#2,1'I,yLi�[.31R'�1 Cert.Tester No.$PO0119yS Date 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