2016_1212 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) ���` �� s �
MAILING ADDRESS: ��� �
CONTACT PERSON/PHONE: � �
LOCATION OF SERVICE: 6c.��1�5 � c C
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
I-�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker I�Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��I19��k.l� Model Number �S'O Size
� y
Located At W1'6T�lQ'L Serial Number� �c� 3-��'
Is the assembly installed in accordance with ma ufacturer 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
�i O
Held at Z �psid Held at Z�' psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked: 1 Leaked'L Did not ope � Did not open � Leaked�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Open d at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model W�� � �s SN:�O(o �� 3'7'
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
FirmName 1� Firm Address3�� ���tL6pC Cv
ca�� � �� ��v
Certified Tester(print) ertified Tester(si re)
Firm Phone#q�c�� � Cert.Tester No.��3 („ Date Z �L
��.
*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