2016 IRRIGATION__� DOMESTIC FIRELINE
The following form must be co`mpleted 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• �(�-�' �Y1c_�f' 4 i i ✓�=---
LOCATION OF SERVICE: �'-�I--T_�{�-1 F��,6't �� t ;C�
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
�l educed Pressure Principle CReduced Pressure Principle-Detector
.�DoubleCheckValve ��Double Check-Detector �"��
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
�Manufacturer �� ���..t+l� Model Number ����1 Size .
� f � �c
Located At l,�c� �+- l'�� � '�"� Serial Number .`� �"� � �
Is the assembly install d 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 �• � psid Opened at Opened at Held at
I�itial Test Closed Tightl�?� Closed Tight �" psid psid psid
j� Leaked�l Leaked'� Did not open � Did not open 1 Leakedl�l
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�� Closed Tight'�: I psid psid psid
Test gauge used: Make/Model j�,'�o��u �fJ dG G T I�j l� SN: G �>( �L l�.>(� :�
Date Tested for Accuracy: .�r" �` ���
Remarks:
The above is certified to be true at the time of testing.
1 .�-- , / �' / � /`�'�
FirmName ,G—,���PS/l�� ��l(�iG�jGP;a Firm Address ;;�-'`� f�, � �/�� ,,,ri � i r��, 5 ii� •
f.- -' � _..--
� A / �'� , ' ,_ T
. � /L Gd � � . _.___ _
Certified Tester(pr�nt s1`� '7� Cert�fied Tester(signature) � ,.--�`";�t� �-%-'����
, _ - �
�
Firm Phone# `��,?r-� �;,��"��1�� Cert.Tester No. �`l � � �1 r� 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