2016_1221 ✓
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: � 't �R—��—Z 9
LOCATION OF SERVICE: "�7 / S G,v►� 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
�oubleCheckValve �Double Check-Detector
�lPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer � � i u'� Model Number �J Size � y
Located At 1—'� O+��' �/G�y °) Serial Number �- S g S ��
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
l st Check 2nd Check
Held at�p d Held at�C> ps' Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leaked❑ Leakedil Did not open � Did not open ❑ LeakedL`-.
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 C� b��.C� ��� S SN: �� O S OS 6 9
Date Tested for Accuracy: ��'�'� �
Remarks:
The above is certified to be true at the time of testing.
FirmName �''`� n L'C!�'�' `� Firm Address �i � , U�x � "��j �.U]/.� C� �
�
Certified Tester(print) �U�� L—�G- Certified Tester(signature � � '�'"����
Firm Phone# �b�l r'�J-j����Cert.Tester No. b U Cl8'ti Date ��Z I� ��
* 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