2016_1219 •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) , 1 1
MAILING ADDRESS: ���3 W na 2sr ��r l
CONTACT PERSON/PHONE: I�.�u�`s i 2� - � �b`�O
LOCATION OF SERVICE: //�0 r" a ye Qr'�C'��r
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
iReduced Pressure Principle '-IReduced Pressure Principle-Detector
�olDouble Check Valve Double Check-Detector
; I Pressur�Vacuum Breaker 1 Spi11-Resistant Pressure Vacuum Breaker
�,U T`( �� m � I Size_�_
Manufacturer lA S Model Number
Located At �i�Y'V 1 L� G-�C`c'Tf`f Serial Number t��� �3 g
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? C�
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 �,�a psid Held at�,` psid Opened at Opened at Held at
I ' ial Test Closed Tight��lo Closed Tight '�� psid psid psid
�a5g Leakedl I Leaked' i Did not open . i Did not open ! Leaked I
Repai rs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight' ; Closed Tight i psid psid psid
Test gauge used: Make/Model��Y1�Ji'ACp ���" z-��� SN: �-������
Date Tested for Accuracy: / ���o ��
Remarks:
The above is certified to be true at the time of testing.
Fir�n Name��e�1 �� Firm Address � ���W(�St �er � E'(I
� Certitied Tester(pr�nr)�U� (� Certified Tester(signature) �
Firm Phone# 2��—T I� ���� Cert.Tester No. oDDIv75S Date ��'� �/ � i�
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REFLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy