2016_1220 IRRIGATION�_ DOMESTIC FIRELW E
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: � G�L 5 �,/�4 ��%�✓
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
.i�ouble Check Valve �: �Double Check-Detector
PressureVacuumBreaker 'Spill-Resistant Pressure Vacuum Breaker
Manufacturer�U f�� I`✓ � Model Number � SO Size�
Located At /`�-�N(' �/A� Serial Number � S �7�-5 ��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � �s
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a�• � psid Held at��psid Opened at Opened at Held at
Initial Test Closed Tighti.:--����� 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 Opened at Held at
Repair Closed Tight'_- Closed Tight psid psid psid
Test gauge used: Make/Modelfl��N,6�/��� �!D�'�t� �h(s' SN: ��r����-!f� �7 7
Date Tested for Accuracy: t� �ci l �
Remarks:
The above is certified to be true at the time of testing.
Firm Name��� �✓�� ^ Firm A ddress G'(.�'����S�1/%C� ��Y/�S'� /�"
f/j'1 r c l���[._ �L� �,C.: 7�
f/.
Certified Tester(print) Certified Tester(signature ��-c! �2�� t�
Firm Phone#���G�3,Z� �-I Cert.Tester No. �l' S 9 CG� Date C� �G � �-
* 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