2016_1228 �
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: �/�f� �i�c���iu's
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: "� �' � ' kC
The backflow prevention assembly detailed below has been te ed and maintained as required by
commission regulations and is certified to be operating within acceptable para�neters.
TYPE OF ASSEMBLY
R�uced Pressure Principle �Reduced Pressure Principle-Detectar
✓Double Check Valve �Double Check-Detector
PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer l�'� ����`�� Model Number 3�� 1CG � Size � ' ��
��
Located At P�- � a►--r � Serial Number ����)��
Is the assembly installed in ac ordance with manufacturer recolnmendations andlor 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 Did not open Did not open Lcaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Hcld at
Repair Closed Tight Closed Tight psid psid psid
Test gauge used: Make/Model 1.�� /G�S' SN: O�f.3 f��-�
Date Tested for Accuracy: � � �S �- / �
Remarks:
The above is certified to be true at the time of testing.
F ��/I
Firm Name / V��f P G Firm Address ,g ��x �lb�%�SS
/
Certified Tester(print) �(gv��� ��Certified Tester(signature) �
Firm Phorie#����/'�? ���3 Cert.Tester No 1-s',� � Date ��c- o�.-p ���
* 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