2016 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) fp `
MAILING ADDRESS: O Z ��s tur� h��4�S � �1�t
CONTACT PERSON/PHONE: No Y�J fl S�
LOCATION OF SERVICE: D 2 � f=�
The backflow prevention assembly detailed below has been teste 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
�y,Double Check Valve �Double Check-Detector
�JPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �Nt���l�S Model Number ��� Size�
L � � ���g �
Located At ��14'K- �2T�.. �l�`+� ���— �eria�l Number
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 Z� psid Held at 2� psid Opened at Opened at Held at
Initial Test Closed Tighti� Closed Tight If� psid psid psid
Leaked❑ LeakedC Did not open � Did not open � Leaked❑
Repairs/
Materials
Used
Held at psid Held psid
Test After Opened at Opened at Held at
Repair Clos Tight� Closed Tight�7 psid psid psid
Test gauge used:Make/Model W 1'��N � —� SN: ��O�GJ, �
Date Tested for Accuracy: �
Remarks:
The above is certified to be true at the time of testing. � .�/
�r�1
FirmName � .G' "rtrm Address 3�Z � 128�a� �V �
G� �Zf)8
Certified Tester(print),� ���Q�'G�rtified Tester(signature)
Firm Phone# {7l'v �SS 88� Cert.Tester No. /Q.�t� Date r� �9
* 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