2016_1221 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: '��( c�m v►'�a� �
The backflow prevention assembiy detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ljeduced Pressure Principle �lReduced Pressure Principle-Detector
gj�ouble Check Valve I 7Double Check-Detector
C1PressureVacuumBreaker C�Spill-Resistant Pressure Vacuum Breaker
Manufacturer �� ���S Model Number �jJ'�'� Size�
Located At_ ����^� Serial Number � s 9 S 9 S y
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�p id Held at�psi Opened at Opened at Held at
Initial Test Closed Tightl� Closed Tight '� psid psid psid
Leaked❑ Leaked�J Did not open I� Did not open �7 Leakedf 7
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ sid
P psid psid
Test gauge used:Make/Model C�'�i/r� '��s' SN: O� �`� `��
Date Tested for Accuracy: j(a-���-s
Remarks:
The above is certified to be true at the time of testing.
Firm Name �.C�W r1 L►�j'�'a Firm Address . U, 07C � -� �/� ��
Certified Tester(print) �U I`� �pQr�` Certified Tester(signature) 2-
Firm Phone# �- ,,����� Cert.Tester No. ��1 ���ate ��Z/ v �
*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