2016_1214 IRRIGATION�_ DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and d�ted original
must be submitted to the public water supplier for recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS: F,�„� �I �lro����`��
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � � � ' Y� K
The backflow prevention assembly detailed below has been tested and maintai d as required by
commission regulations and is certified to be operating within acceptablc parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle Reduced Pressure Principle-Detectar
n�ouble Check Valve Double Check-Detector
PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer w�r��� � S Model Number���� X'L >'" Size �f/. r
Located At-�-�-y ou�� y � Serial Number/-t ,� � �il l�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?�y�"°S'
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Asseinbly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at `�.�psid Held at ,�.5 psid Opened at Opened at Held at
Initial Test Closed Tight+� Closed Tight t✓ 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 !/�r�/fj� u �► SN: ��f 3 /'� � �
Date Tested for Accuracy: ��� /' pi�--/ -E'
Remarks:
The above is certified to be true at the time of testing.
Firm Name �� �t-✓�%�� Firm Address .c�3� ' �O " �5 ,ffd : 6"a�G
�--C`_'_....-._._
Certified Tester(prinr) � 0.11��-OS ��ertified Tester(signature)
Firm Phone# `�t��'- ��t� .`��%� Cert.Tester No � '� 6`c� ,3C '� 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