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: �,��-- -� �
LOCATION OF SERVICE: � �� r- '� � 1 1� '�L I i
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 C Double Check-Detector
❑PressureVacuumBreaker �JSpill-Resistant Pressure Vacuum Breaker
, ) � � ��
Manufacturer �'V � � K f Ol`J Model Number '��i' Size /
� ,:�� !;`M. �_, � �
Located At �� Ur�� 6/r� �� -`'��� f� Serial Number =' `� � i ' ' -
Is the assembly insta ed in accordance with manufacturer recommendations and/or local codes? -E-.�
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 •� psid Held at 2•� psid pened at Opened at Held at
, itial Test Closed TightC4Y' Closed Tight ' psid psid psid �
�� Leaked� LeakedLl Did not open ❑ Did not open J Leaked�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�J Closed Tight� psid psid psid
�
Test gauge used:Make/Model�����;�� ���C:�>� ��-��--� SN: �� :,����� ���.D''�-
Date Tested for Accuracy: �` tU �" ��.�%
Remarks:
The above is certified to be true at the time of testing.
FirmName ��<��'�'CJ�' �-{'��/ G�t7�1Firm Address .�'.fi` �'//i J�UeLJ j_.�f%�'��c-S
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Certified Tester(print) - .r� �6'��` Certified Tester(signature) �''.��=���
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,r/ � ]� '��� '��,,} t ' ':�'i
Firm Phone# `�����'�'k�4��' Cert.Tester Nol`,? -l✓�J ; �•� � 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