2016_1118 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 LD. #0570040
(Customer)
MAILING ADDRESS: SG�D
CONTACT PERSON/PHONE: � �t/�4 - ' �
LOCATION OF SERVICE: Qt CaTT
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 �7Reduced Pressure Principle-Detector
�Double Check Valve �Double Check-Detector
�IPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer�,(Ji4TTS Model Number,l/COd7/�/C�% Size!//��N
Located At� �itGt �`1]C'r' TO�(/�1�'K J�j�fiU!'� Serial Number OT (Y���
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? LS
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a�,� psid Held�psid Opened at Opened at Held at
Initial Test Closed Tightl74 Closed Tight �' psid psid psid
Leaked�� Leaked'�.1 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�:J Closed Tight� psid psid psid
Test gauge used:Make/Model LLd D• DQ ��T/lSU SN: �a �j1sd.�
Date Tested for Accuracy: �
Remarks: l�(//�'�--T'E�( S�FTt�1/tK
The above is certified to be true at the time of testing.
FirmName �UpU�L Firm Address ' af `�ilvi �a� �Gl �.C��l,bw
�< S�0(a
Certified Tester(print)� 5 t�N L( �L F f Certified Tester(signatur
Firm Phone# 97.� ������D Cert.TesterNo.�/'dD���D�i Date /� / i6
* 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