2016_1121 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: � }�-(L� 6
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 Double Check-Detector
-'Pressurc Vacuum Breaker Spill-R�,sistant Pressure Vacuum Breaker
3 SZ�
Manufacturer ��L�11�'� Model Number _ U �_ T Size�
Located At ��� Z ��/� Serial Number� � '��3 Z_
Is the assembly installed in accordance with manufacturer recommendarions 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 Opencd at Held at
Repair Closed Tight Closed Tight psid psid psid
Test gauge used: Make/Model (.,E�./���1"�`t-� SN: � � 2 � �
Date Tested for Accuracy: � �a�� 1 �
Remarks:
The above is certifi d t be tr e�t the time of testing.
�anc�ara Irr�atron Gcindara trrigation
3901 Cl�on Dr. 3901 Cl�on Dr.
FirmName Richardson, Tx. 75082 Firm Address Richardson, Tx. 75082
Certified Tester(print) L' � ���(l/�'Certified Tester(signature)
Firm Phone# l ��� � �C/�� Cert.TesterNo. ���� �5�,� Date � �^Z��b
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy