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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACTPERSON/PHONE: `1(,Oa,�. ��''I'���ZI�_
LOCATION OF SERVICE: "�i I q �'IC.m i'h(�rti d ��'•
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
�❑ duced Pressure Principle �Reduced Pressure Principle-Detector
ouble Check Valve ❑Double Check-Detector
�IPressureVacuumBreaker �iSpill-Resistant Pressure Vacuum Breaker
Manufacturer �,�,� � \�,�-��� Model Number ��� Size��
Located At .- Serial Number !"T S � S��v
Is the assembly installed in acco ance 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 Z•� id Held at�psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight _ psid psid psid
LeakedC Leaked[7 Did not open C Did not open ❑ Leakedn
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight�i ClosedTight n psid psid psid
Test gauge used: Make/Model �-0Y1��� T�.G - s SN: � Z � ,`j JS6�
Date Tested for Accuracy: ( 0"'� -� j�
Remarks:
The above is certified to be true at the time of testing.
Firm Name ��n �-� � �►� Firm A ddress � U � 1f7 Q� � �b �U�J�e G� �y
�
Certified Tester(print) �`� ��`� �0�.(M Certified Tester(signature) ���
Firm Phone#_�6�''?j 3� �Zr 9R Cert.Tester No. iJ V o'�7i Date (2�Z�'�-�
*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