2016_1221 ��
IRRIGATION v 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: '-C? �69-33�5 2 I4`l
LOCATION OF SERVICE: _�, ��(�� I'1 c.Yn ''n �n d 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
❑• �educed Pressure Principle ❑Reduced Pressure Principle-Detector
�DoubleCheckValve �Double Check-Detector
�PressureVacuumBreaker :�Spill-Resistant Pressure Vacuum Breaker
Manufacturer (}J � � 1�' rS Model Number �7-�V Size .� �
Located At
��v� �' Serial Number � S' � S��7
Is the assembly installed in accordance with manufacturer recommendations and/or 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�p d Opened at Opened at Held at
Initial Test Closed Tightl4� Closed Tight � psid psid psid
Leaked'�� Leaked���] Did not open - Did not open ��'� LeakedG
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
S �vSvS�9
Test gauge used:Make/Model �1'�6 .O � SN:
Date Tested for Accuracy: ��"'7���
Remarks:
The above is certified to be true at the time of testing.
Firm Name �G,�.J�l L�C� u,i � Firm A ddress ��• �x 1�6 ,�G�Se c>� �
Certified Tester(print) 1Wo l�" �e�`�' Certified Tester(signature) � "'�
Firm Phone# ��/ �3��'���� Cert.TesterNo. ,������ Date��/�� ��
* TEST RECORbS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy