2016_1208 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) . 2
MAILING ADDRESS � � �O E V�. �
CONTACT PERSON/ ONE: - I
LOCATION OF SERVICE: �
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 [:,�Reduced Pressure Principle-Detector
�oubleCheckValve /���ouble Check-Detector
❑PressureVacuumBreaker � ❑Spill-Resistant Pressure Vacuum Breaker
�� ��
Manufacturer nlls Model Number ����,� Size�
Located At � ��� 1,7 Serial Number 35� t�i�►
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? IEiJ
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
lst Check 2nd Check
�� Held at�.0 psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight'� Closed Tight � psid psid psid
Leaked�� Leakedl I Did not open � Did not open 1 Leaked�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight 17 psid psid psid
Test gauge used:Make/Model �L�\ SN: ���1
Date Tested for Accuracy: `� l �D
Remarks:
The above is certified to be true at the time of testing.
n �`
Firm Name ���� �j CNUµ9 Firm Address � 0� l'� •
Certified Tester(print) �r�h�t� Y Certified Tester(signature)
Firm Phone#��-�'�`(�--I/-�� Cert.Tester No. Date t
*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