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: � 1p+ ��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
��� iR uced Pressure Principle Reduced Pressure Principle-Detector
ouble Check Valve Double Check-Detectar
�1PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer �� L ���',� Model Number �� Size�
Located At T ��✓� �1��'� Serial Number�,� �{ ,��3
Is the assembly installed 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�i� Closed Tight� psid psid psid
Leaked i Leaked. ��� Did not open Did not open Lcaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opencd at Held at
Repair Closed Tight I Closed Tight �� psid psid psid
Test gauge used: Make/Model C.,����� SN: ��2 � �
Date Tested for Accuracy: l� —d�—L��
Remarks:
The above is certified to be true at the time of testing.
Gandara l'r�atiort Gandara IrrigaCion
3901 Cl�on Dr. 3901 Cl�on Dr.
FirmName Richardson. Tr �5�� Firm Address ic r
Certified Tester(pr nt) �� ����(�f; Certified Tester(signature)
Firm Phone# / 7Z y�¢ Z ��� Cert.Tester No. ���� Date �f 2�'���
* 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