2016 IRRIGATION�_ DOMESTfC 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�
LOCATION OF SERVICE: ��{-� t�i�f)1��1r%�)r'i���",� `"� 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
�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�f'�bouble Check Valve C Double Check-Detector
�JPressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker
� .-� �r ;I ���
Manufacturer �,; ��,j i"'`�' Model Number �`_?L.�" Size i
Located At Y``T ��,� � k'- Serial Number � ��� �+'�°�
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 �. � � psid Held at 1 ,� psid Opened at Opened at Held at
��„�"t.�'
Imtial Test Closed Tight�'" Closed Tight� psid psid psid
Leakedl�� Leaked'. I Did not open �I Did not open ❑ Leakedl�l
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
� ' f �-- l SN ;,.,,�l j�� � � �,
Test gauge used: Make/Model .�t (i'v(�t� `7��4='��'/��,� . �. L j
Date Tested for Accuracy: f��(- ` 1 L-
Remarks:
The above is certified to be true at the time of testing.
, `
Y
Firm Name � /:+���.��I���Y- �_.i�"� (��������� ►'" iFirm Address?, % �'- ���:�r ��,' �� `� �4�; � j- j. y.�-. •
� � � �.i � � '� �
Certified Tester(prnt)�__��tv�il !,�,��y''`':i! Certified Tester(signature)f ,�!�"�-_,,�„�'`� �---� �
r ; `� �
Firm Phone#� ': ,' i';r ��', ' `a �::-.~ %f Cert.Tester NoJ:'�I���!f.�_. ��`� `, c.,� 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