2016_1221 .1--�'�
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: I'��d`� -�i - 38-? j 4
LOCATION OF SERVICE: T_1-Ic�mM�ri� S
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
�ouble Check Valve ❑Double Check-Detector
�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer w � ��'"�'S Model Number 3 �� Size ���
Located At �`�n�'� �t J Serial Number I�' 6 a 9z z d
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 1l'es'
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
I st Check 2nd Check
Held at �� psid Held at�ps' Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked'�,1 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 CD✓1 brc�C o TlC�J�' SN: OZ v S �S 6 9
Date Tested for Accuracy: f 0 -7-I�"
Remarks:
The above is certified to be true at the time of testing.
Firm Name �-a-w'R L�9 ta,�d Firm Address 9"� � � ,�OX ��� l�Uy,� G;.;�j
�
Certified Tester(print) ���� �J�`�- Certified Tester(signature) �— ��
� �
Firm Phone# 6�- �i 3�'S''Z�9'9 Cert.Tester No. �v�Z�g Z Date� �21 � �
* 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