2016 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• JC G�� '� �
LOCATION OF SERVICE: ��� �-�� /ti�l�r��U/��� �
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 �IReduced Pressure Principle-Detector
�ubleCheckValve !�Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
, . - �-,. )/
Manufacturer �,�1 �i�!/')S Model Number �2 h` � Size�_
Located At �' Serial Number �'`1 1) �7 �7�=�
Is the assembly nstalled in accordance with manufacturer recommendations and/or local codes? ...5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
,t�,�p� Held at z�� psid Held at�psid Opened at Opened at Held at
Imtial Test Closed Tight� Closed Tight � psid psid psid
Leaked❑ Leaked� Did not open � Did not open I Leaked'� I
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 ��a f�����J�k� �� SN: C� �0�� �G��
Date Tested for Accuracy: 5 —�G �
Remarks:
The above is certified to be true at the time of testing.
Y / irm Address , F'�/? S V i v -
Firm Name��}��/T�� ,I%�_��" ���j`� l " ��`"�`.�'� ;��L' `l �
�.
� '
Certified Tester(prnt � � OC�l'�� Certified Tester(signature) � �"" � �
, .� �. � ,.
Firrn Phone#���' �,�:.� `���� Cert.Tester No. � '�� �� � Date
*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