2016_1216 IRRI6ATION " 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: �I � �2��f0 � f
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
R�duced Pressure Principle Reduced Pressure Principle-Detector
•�ybouble Check Valve �Double Check-Detectar
-PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer w< <-�- �ti,� Model Number 3 � Size�
Located At ����� �1�-��`� Serial Number � -���� � (
Is the assembly installed in accardance 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 Z� ps' Held at�psi Opened at Opened at Held at
Initial Test Closed Tight � Closed Tight psid psid psid
Leaked Leaked ' 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 (C.����/d--� SN: �� � � �
Date Tested for Accuracy: l ( — �/ �
Remarks:
The above is certified to be true at the time of testing. �ng�C�t n�5082
Gandara Irrigation �Zichardson, Tx•
3901 Cl�on Dr.
FirmName Rtchardsnr,, Tx_ �sa�� Firm Address
Certified Tester(pr�nt)�(� ��,�f},Q/� Certified Tester(signature) �
.�
Firm Phone# �7� ���o ?. Q��l Cert.Tester No�t'f.�3/S Z Date ����v�'�
* 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