2016_1212 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: U s � � ' �
CONTACT PERSON/PHONE: r 1
LOCATION OF SERVICE: J
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
C�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer V'"� � � Model Number L FQ^�/" 7 1'�fi Size �
Located At ���'�� Serial Number Q�����
Is the assembly ' tins alled 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
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked� Leaked I Did not open ❑ Did not open ❑ Leaked❑
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�-p�+/Il� �I/��i/���� SN: r�i r����
Date Tested for Accuracy: d�-�7-/�i
Remarks:
rJ ��,�'1 .rL�'
The above is certi ed to be true at the time of testing.
Firm Name,(�� /�K..C(/ryJ�'{,(,� ���F��li.}� Firm A ddress �� `1'-J. L�J h�.� 7��]r
6
Certified Tester(print) �� ����Certified Tester(signature) �'����
Firm Phone#�/7�.���f�� Cert.Tester No. � 1�S7 Date��'�Z�! �%'
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tes�er's Copy